Form Vtr-61 - Rebuilt Vehicle Statement Page 2
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1
2Rebuilt Vehicle Statement
These sections must be completed by the rebuilder if the vehicle has been repaired, rebuilt, reconstructed, or assembled with any of the listed component parts.
Component Parts – Engine, Frame, and Body
Origin of Component Part/Purchased from:
Component Part Number
Component Part
(Name and Complete Address)
(required)
Engine
Frame
Body
Note: Ownership evidence (bill of sale and/or title) is required if an engine, frame, or body is used.
Component Parts – Other
Origin of Component Part/Purchased from:
Component Part Number
Component Part
(Name and Complete Address)
(if available)
Transmission
Fender(s)*
Hood
Door(s)*
Bumper(s)*
Quarter Panel(s)*
Tailgate/Deck Lid/ Hatchback
Pickup Cargo Box (vehicle
10,000 pounds or less)
Cab of a Truck
Roof or Floor Pan (passenger
vehicle, if separate from body)
Note: Submit any bills of sale for these component parts (if any).
*
Specify the location of the component part on page 1 in the “Details of Work Performed” section.
VTR-61 Rev 09/16
Form available online at
Page 2 of 2
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