Application For Salvage Certificate Of Title - Alabama Department Of Revenue
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1
2A
D
R
LABAMA
EPARTMENT OF
EVENUE
APPLICATION
M
V
D
– T
S
OTOR
EHICLE
IVISION
ITLE
ECTION
See instructions and
MVT 41-1
exemptions on
P. O. Box 327640 • Montgomery, AL 36132-7640
R 1/12
reverse of form.
Application For Salvage Certificate of Title
TYP
OR PRINT
THIS FORM MAY BE DUPLICATED OR ADDITIONAL COPIES MAY BE OBTAINED FROM
ONLY
THE DEPARTMENT WEB SITE AT
*
VEHICLE IDENTIFICATION NUMBER
TRANS
YEAR
MAKE
MODEL
V
CODE
MODEL
E
I
10
H
N
I
F
CYLS
NEW
USED
DATE OF PURCHASE
NUMBER
COLOR
ODOMETER READING
*
CURRENT ALABAMA TITLE NO.
C
O
LIENS
L
E
FELONY OFFENSE FOR FALSE ADDRESS
NAME(S) (Last Name, First, Middle)
APPLICANT SHALL DISCLOSE ODOMETER READING (check one)
O
I
ACTUAL MILEAGE
W
CURRENT MAILING ADDRESS
N
N
F
E
EXCEEDS MECHANICAL LIMITS
O
CITY
STATE
ZIP
R
NOT ACTUAL MILEAGE — WARNING, ODOMETER DISCREPANCY
DEPARTMENT USE ONLY
(DO NOT ENTER IF LIEN RELEASED)
NAME
LIEN DATE
F
L
I
ADDRESS
I
R
E
S
N
CITY
STATE
ZIP
T
FELONY OFFENSE FOR FAILURE TO NAME LIENHOLDER WITH INTENT TO DEFRAUD
(DO NOT ENTER IF LIEN RELEASED)
NAME
LIEN DATE
S
E
L
ADDRESS
C
I
O
E
N
N
CITY
STATE
ZIP
D
FELONY OFFENSE FOR FAILURE TO NAME LIENHOLDER WITH INTENT TO DEFRAUD
LOCATOR NO.
OWNER(S) AUTHORIZATION FOR SPECIAL MAILING
I, WE, HEREBY AUTHORIZE MY SALVAGE CERTIFICATE OF TITLE TO BE MAILED TO (IF NO LIENS LISTED HEREON):
REJECT TO:
REASONS:
NAME
ADDRESS
EXAMINER NO.
ENCL:
CITY
STATE
ZIP
A
SPECIAL MAILING (IF NO LIENS LISTED HEREON):
__________
__________________________
_________
In accordance with Section 32-8-87, Code of Alabama 1975, the motor vehicle described above was determined to be a salvage vehicle on the
day of
,
.
_____________________________________________________________________________________________________
CITY/STATE WHERE TOTAL LOSS OCCURRED
CHECK THE BLOCK IF TOTAL LOSS WAS DUE IN PART TO WATER DAMAGE
CHECK THE BLOCK ONLY IF THE VEHICLE IS JUNK OR TO BE SOLD FOR PARTS ONLY
**
**
A VEHICLE THAT IS JUNK OR SOLD FOR PARTS ONLY CAN NOT BE REBUILT OR RETITLED IN ALABAMA.
I, THE UNDERSIGNED, CERTIFY THAT THE VEHICLE DESCRIBED ABOVE IS OWNED BY ME AND I HEREBY MAKE APPLICATION FOR A SALVAGE CERTIFICATE OF TITLE FOR SAID MOTOR VEHICLE AND THIS VEHICLE WILL NOT BE THE
SUBJECT OF LIEN PRIOR TO RECEIPT OF TITLE UNLESS INDICATED ABOVE, I FURTHER CERTIFY THAT ALL INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
________________________________________________________________________________________________________________
OWNER’S SIGNATURE(S)
DATE
(PERSONALLY SIGNED BY EACH OWNER (IN INK) OR AUTHORIZED REPRESENTATIVE OF FIRM)
B
NAME AND ADDRESS OF INSURANCE CO. AND ADJUSTING CO. (IF ANY)
NAME OF COMPANY
NAME OF COMPANY
STREET ADDRESS
STREET ADDRESS
CITY
STATE
ZIP
CITY
STATE
ZIP
ADJUSTER’S NAME (TYPE OR PRINT)
ADJUSTER’S NAME (TYPE OR PRINT)
TELEPHONE NUMBER
TELEPHONE NUMBER
_________________________________
INSURANCE COMPANY CLAIM OR POLICY NUMBER
CHECK THE BLOCK IF TOTAL LOSS WAS DUE IN PART TO WATER DAMAGE
**
CHECK THE BLOCK ONLY IF THE VEHICLE IS JUNK OR TO BE SOLD FOR PARTS ONLY
**
A VEHICLE THAT IS JUNK OR SOLD FOR PARTS ONLY CAN NOT BE REBUILT OR RETITLED IN ALABAMA.
I, THE UNDERSIGNED, CERTIFY THAT ALL INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND THAT
THE VEHICLE DESCRIBED ABOVE WAS DECLARED A TOTAL LOSS, COMPENSATION PAID THE OWNER BY THE ABOVE NAMED INSURANCE COMPANY AND SAID INSURANCE COMPANY HEREBY MAKES APPLICATION FOR A SALVAGE
CERTIFICATE OF TITLE. THE OUTSTANDING CERTIFICATE OF TITLE, PROPERLY ASSIGNED, IS ATTACHED HERETO.
________________________________________
THE OWNER WISHES TO RETAIN THE SALVAGE ON MENTIONED VEHICLE.
DATE VEHICLE DECLARED A TOTAL LOSS:
______________________________________
CITY/STATE WHERE TOTAL LOSS OCCURRED:
INSURANCE COMPANY’S
________________________________
________________________________________________________________________
DATE
REPRESENTATIVE SIGNATURE
(PERSONALLY SIGNED (IN INK) BY AUTHORIZED REPRESENTATIVE OF FIRM)
Submit $15.00 Application Fee in certified funds (non-refundable)
*
All VINs for 1981 and subsequent year model vehicles that conform to federal
anti-theft standards are required to have 17 digits/characters.
payable to the Alabama Department of Revenue.
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