Fillable Form Mvr-4f - Affidavit And Notification To Owner printable pdf download

North Carolina Department of Transportation

Front MVR‐4F

DIVISION OF MOTOR VEHICLES

(Rev.11/13)

AFFIDAVIT AND NOTIFICATION TO OWNER

$15.00 FEE

VEHICLE SECTION

TITLE NUMBER

YEAR

MAKE

VEHICLE IDENTIFICATION NUMBER

BODY STYLE

OWNER/REGISTRANT SECTION

Owner 1 ID # ___________________ ______________________________________________________________________________________________

Full Legal Name of Owner/Registrant 1 (First, Middle, Last, Suffix) or Company Name

Owner 2 ID # ___________________ ______________________________________________________________________________________________

Full Legal Name of Owner/Registrant 2 (First, Middle, Last, Suffix) or Company Name

Residence Address (Individual) Business Address (Firm)

City and State

Zip Code

County

Mail Address (if different from above)

SECTION A: CERTIFICATION BY INSURANCE COMPANY

(COMPLETE IF TOTAL LOSS CLAIM WAS PAID)

This is to certify that the insurance company listed below has paid a total loss claim on the above listed vehicle. I also certify that a notice requesting

the title was sent via certified mail to the owner and any recorded lienholder at least 30 days prior to submitting this form to the Division. Proof of

payment of a total loss claim to the lienholder (if applicable)/owner is attached showing evidence that funds were paid to the first recorded

lienholder shown in the Division's records. I certify that all information and supporting documents submitted are true and accurate.

Proof of payment of total loss claim and proof of request for title sent to the Owner/Lienholder MUST be attached to this form.

Name of Insurance Company

Name of Claims Representative

Claim number

Phone # of Claims Representative

Address

City

State and Zip Code

SECTION B: CERTIFICATION BY DEALER

(COMPLETE IF TOTAL LOSS CLAIM WAS NOT PAID)

This is to certify that I am a North Carolina used motor vehicle dealer whose primary business is the sale of salvage vehicles on behalf of insurance

companies. I also certify that upon receiving a release statement from the insurer, a notice requesting the owner and any recorded lienholder to pick

up the vehicle was sent via certified mail at least 30 days prior to submitting this form to the Division. I have attached the release from the insurer,

copy of the notice and proof of delivery. I certify that all information and supporting documents submitted are true and accurate.

Proof of notice sent to the Owner and/or any Lienholder MUST be attached to this form.

Name of Dealer

Name of Agent for Dealer

Address

City

State and Zip Code

Notice Sent To:(Owner Name and Address)

Date Notice Mailed:

Notice Sent To:(Lienholder Name and Address)

Odometer

To my knowledge the vehicle described herein:

Yes No Has been involved in a collision or other occurrence to the extent that the cost to

repair exceeds 25% of fair market retail price.

_________________

Yes No Has been a flood vehicle, a reconstructed vehicle or a salvage vehicle.

ONC

(odometer not certified)

Disclaimer : G.S. 20‐109‐1 (b) (2) "The Division shall not be subject to a claim under Article 31 of Chapter 143 of the General Statutes related to the cancellation of a title

pursuant to this section if the claim is based on reliance by the Division on any proof of payment or proof of notice submitted to the Division by a third party pursuant to

subdivision (b) (2) or subsection (e1) of this section.

Signature of Authorized Agent or Representative __________________________________________________________________________________

Date _______________________________ County __________________________________________ State _____________________________________

I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she voluntarily signed the

foregoing document for the purpose stated therein and in the capacity indicated: _________________________________ (Name(s) of Principal(s)).

Notary Signature _____________________________________________ Notary Printed Name ______________________________________________

(SEAL)

My Commission Expires ____________________________________________

Form Mvr-4f - Affidavit And Notification To Owner

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