Fillable Vehicle Dealer Closeout Statement Form printable pdf download

Vehicle Dealer Closeout Statement Form

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Michign Department of State

Bureau of Driver and Vehicle Programs- Business Licensing Section

Lansing, Michigan 48918

MICHIGAN VEHICLE DEALER CLOSEOUT STATEMENT

(Temporary Location)

(Please type or print legibly)

Dealer Number: _________________________

Temporary Dealer Number : ____________________

Primary Licensed Location: ___________________________________________________________________________________

(Street Address)

(City)

(ZIP Code)

Temporary Licensed Location: ________________________________________________________________________________

(Street Address)

(City)

(ZIP Code)

Date(s) of Sale:

From ______________ To: ______________

I, ________________________________________________________________ as _________________________________________

(Name)

(Title)

of _________________________________________________________ , do certify that I will discontinue doing business as a

(Name of Dealership)

Michigan Vehicle Dealer at the above temporary location, effective ___________________ .

(Date)

I certify that I will surrender my temporary license to:

The Secretary of State branch office located at ____________________________ on _______________ .

(Location)

(Date)

The Bureau of Driver and Vehicle Programs, Lansing, Michigan on

_________________ .

(Date)

I further certify that I have disposed of vehicles that were in our inventory at the temporary location, or have

moved the vehicles to my primary licensed location.

My dealer records, including those from my temporary location, will be available for inspection at my primary

_______________________________________________________________________

licensed location:

(Street Address)

(City)

(ZIP Code)

I certify that all the statements I have made herein are true and accurate to the best of my knowledge, and that untrue or

misleading information may be grounds for administrative action against my primary dealer license.

Signed, X _________________________________________________________________

_____________________

(Signature and Title)

(Date)

(Rev. 04/2013)

Vehicle Dealer Closeout Statement Form

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