Form Mvt 41-1 - Report Of Total Loss Settlement, Scrapped, Dismantled, Or Destroyed Vehicle And Application For Salvage Certificate Of Title - Alabama Department Of Revenue

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Report of Total Loss Settlement, Scrapped,
ALABAMA DEPARTMENT OF REVENUE
MOTOR VEHICLE DIVISION — TITLE SECTION
Dismantled, or Destroyed Vehicle and
P.O. BOX 327640, MONTGOMERY, AL 36132-7640
Application For Salvage Certificate of Title
*APPLICANT SHALL DISCLOSE
APPLICATION
___
ACTUAL MILEAGE
___
MVT 41-1
EXCEEDS MECHANICAL LIMITS
NOTE: FEE OF $15.00 FOR A SALVAGE CERTIFICATE
___
R 7/96
WARNING — ODOMETER DISCREPANCY
OF TITLE MUST ACCOMPANY THIS APPLICATION.
TITLE NUMBER
VEHICLE IDENTIFICATION NUMBER
TRANS. CODE YEAR MODEL
MAKE
MODEL
BODY TYPE
PREVIOUS ALABAMA TITLE NO.
V
E
10
I
H
N
I
F
CYLS
NEW
USED
DEMO
DATE OF PURCHASE
NO. LIENS
COLOR
ODOMETER READING
DEPARTMENT USE ONLY
C
*
O
L
E
O
FELONY OFFENSE FOR FALSE ADDRESS
DEPARTMENT USE ONLY
NAME
W
N
MAILING
E
ADDRESS
R
I
N
F
CITY
STATE
ZIP
O
R
ALABAMA RESIDENT ADDRESS IF DIFFERENT FROM ABOVE:
M
A
NAME
T
I
ADDRESS
COUNTY
O
N
CITY
STATE
ZIP
I
FIRST LIENHOLDER
L
N
I
F
NAME
E
O
N
R
ADDRESS
LIEN DATE
H
M
O
A
CITY
STATE
ZIP
L
T
D
I
E
O
R
N
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
Section 1 of Act No. 406 passed by the 1995 regular session of the Alabama Legislature known as The Alabama Uniform Certificate of Title and Antitheft Act states in part:
Each owner of a motor vehicle and each person mentioned as owner in the last certificate of title who scraps, dismantles, destroys or changes the motor vehicle in such a manner that it is not the same motor vehicle described in the certificate of origin or
certificate of title, shall as soon as practicable cause the certificate of origin or certificate of title, if any, and any other documents or information required by the department to be mailed or delivered to the department for processing.
In compliance with the above the undersigned does hereby submit this form certifying that the motor vehicle described above was on
WRECKED
RECOVERED THEFT
__________
__________________________
_____
the
day of
, 19
.
SCRAPPED
DISMANTLED
OR
______________________________________________
DESTROYED
THIS VEHICLE IS SOLD FOR PARTS ONLY
Title No.
issued by the State of
____________________________________________________
is attached hereto.
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
DATE
_____________________________________________________________________________________________________________________
SIGNATURE(S)
(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 HERE IF VEHICLE IS A RECOVERED THEFT
CHECK HERE IF VEHICLE IS SOLD FOR PARTS ONLY
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:
INSURANCE COMPANY’S
________________________________
________________________________________________________________________
DATE
REPRESENTATIVE SIGNATURE
(PERSONALLY SIGNED (IN INK) BY AUTHORIZED REPRESENTATIVE OF FIRM)
SEE INSTRUCTIONS ON REVERSE SIDE

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