Note: If your state requires this document of licensing your boat, please contact Advanced Elements Customer
Service Department for completion, or for more information.
MANUFACTURER’S STATEMENT OF ORIGIN
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 Model Year Manufacturer’s Hull Identification#
m
Dragonfly™ Kayak (AE1001) __________ HIN# ___________________________
Type: Kayak Hull Material: PVC/Polyester
Length Overall: 8’4” Beam: 34”
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
TM
P.O. Box 5128 Concord, CA 94524
Signature_________________________________________________________________________________
FIRST ASSIGNMENT
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 Date To whom Due Address
___________________ __________ __________________ ___________________________________
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 Date commission expires_______________
(SEAL)
