Affirmation Supporting Salvage Certificate
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Office of the Secretary of State
AFFIRMATION SUPPORTING SALVAGE CERTIFICATE
This form must accompany all Salvage Certificates for which a Certificate of Title is requested.
State of Illinois
County of ______________________________
Rebuilder’s Name
Rebuilder’s #
Yr.
Contracted Rebuilder’s Name
Rebuilder’s #
Yr.
The undersigned hereby affirms to be the owner(s) of the below described vehicle, acquired by Salvage Certificate
No. ____________________________ Acquired from _______________________________________________________________________________________________
Yr. ______________ Make ______________________________________ VIN ___________________________________________________________________
Complete Section A or B:
A.
Rebuilder states that of parts listed on the reverse side of this affirmation, only the following have been changed:
Type of Part
VIN
Year
Make
Acquired From
________________ _________________________
____ __________
_________________________
________________ _________________________
____ __________
_________________________
________________ _________________________
____ __________
_________________________
________________ _________________________
____ __________
_________________________
________________ _________________________
____ __________
_________________________
________________ _________________________
____ __________
_________________________
________________ _________________________
____ __________
_________________________
________________ _________________________
____ __________
_________________________
Rebuilder personally rebuilt the vehicle, or personally supervised its rebuilding. Rebuilder personally inspected
the completed vehicle, and it complies with all safety requirements set forth in the Illinois Compiled Statutes,
Chapter 625, and any regulations promulgated thereunder by the Secretary of State.
B.
Rebuilder affirms that no essential parts have been removed, replaced, or damaged by flood, and that
completion of this affirmation provides that this vehicle need not complete a successful salvage inspec-
tion as prescribed under Section 5/3-308 of the Illinois Compiled Statutes. Rebuilder further affirms that
the vehicle was personally inspected, and it complies with all safety requirements set forth in the Illinois
Compiled Statutes, Chapter 625, and any regulations promulgated thereunder by the Secretary of State.
I affirm, under penalty of perjury, that all information contained in this affirmation and its attachments is true and
correct to the best of my knowledge.
______________________________________________________
(Signature of Rebuilder or Authorized Agent)
______________________________________________________
Date
______________________________________________________
(Signature of Contracted Licensed Rebuilder)
______________________________________________________
Date
Printed by authority of the State of Illinois. June 2016 — 1 — RT 11.14
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