Statement Of Origin - Advanced Elements Lagoon1 AE1031 Owner's Manual

Note: If your state requires the licensing of this boat, please use the form below. If you need any assistance filling
out this form, please contact Advanced Elements Customer Service Department.
FOR A VESSEL SOLD IN THE STATE OF_____________________________________
The undersigned manufacturer hereby certifies that the new boat described below, the property of
said manufacturer, has been transferred this _________day of _____________________, 20_________on
Invoice# _________________to:
Owner's/Dealer's Name_____________________________________________________________
Address___________________________________________________________________________
City, State, Zip______________________________________________________________________
Model Name
m Lagoon1™ Kayak (AE1031)
Type: Kayak
Length Overall: 8'4"
U. S. Coast Guard Capacity Plate Information (where applicable):
Maximum persons capacity in whole persons: 250 lbs (113 kg)
Maximum weight capacity (persons & gear): 250 lbs (113 kg)
The manufacturer further certifies that this was the first transfer of such new boat and that all
information given herein is true and accurate to the best of their knowledge
Signature_________________________________________________________________________________
FOR VALUE RECEIVED, in the amount of $ __________________________________________________,
the undersigned hereby transfers the Certificate of Origin and the boat described therein
to _______________________________________________________________________________________
Address __________________________________________________________________________________
and certifies that the boat is new and has not been registered in this or any other state; Advanced
Elements, Inc. also warrants the title of said boat at time of delivery, subject only to the liens and
encumbrances as set out below:
Amount of Lien
___________________
Dates___________________________ 20 _________, at _____________________ ____________________
___________________________ By:___________________________________________________________
Transferrer (Firm name) Sign Here ___________________________________________________________
Before me personally appeared _____________________________ who by me being duty sworn under
oath says the statements set forth above are true and correct. Subscribed and sworn to me before
this __________ day of _____________________________ 20 ___________.
___________________________________Notary Public
(SEAL)
MANUFACTURER'S STATEMENT OF ORIGIN
Model Year
__________
Hull Material: PVC/Polyester
Beam: 34"
P.O. Box 5128 Concord, CA 94524
FIRST ASSIGNMENT
Date To whom Due
__________ __________________ ___________________________________
Manufacturer's Hull Identification#
HIN# ___________________________
TM
Address
Date commission expires_______________
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