Damage Disclosure Statement
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1
2Form 411108
01-05
DAMAGE DISCLOSURE STATEMENT
Please read the information on the reverse side before completing this form.
I
(seller) hereby certify that the
following damage disclosure statement is true and correct for the following described motor vehicle:
year,
make,
VIN.
SECTION 1.
The seller must complete Section 1 if any of the following conditions apply:
the Iowa title was issued prior to January 1, 2005;
the Iowa title is not available;
the face of the seller's Iowa title contains no indication that the vehicle was previously salvaged, titled as a salvage, rebuilt,
or flood and the seller knows or reasonably should know that the vehicle was previously salvaged, titled as a salvage,
rebuilt, or flood in another state;
the motor vehicle is a new vehicle sold in Iowa with 1,000 miles or less that has sustained damage exceeding 50% of its
fair market value.
1. I have knowledge the motor vehicle is now or was previously titled as salvage, rebuilt or flood in this state or any other state:
Yes
No.
2. If you answered "No" to question #1, complete the following:
I have knowledge that, prior to or during the time I owned the motor vehicle, it sustained damage for which the cost of
repair exceeded 50% of the fair market value before it became damaged.
Yes
No
3. I have knowledge that the current motor vehicle certificate of title shows that there was prior damage to the motor vehicle:
Yes
No.
SECTION 2.
The buyer must complete this Section if:
The vehicle was purchased from a non-resident.
OR
The vehicle was acquired through a transfer by operation of law (see page 2).
1. I have knowledge the motor vehicle was previously titled as salvage, rebuilt or flood in this state or any other state.
Yes
No.
.
2. If you answered "No" to question #1, complete the following, unless you are surrendering a foreign salvage title or equivalent:
I have knowledge that, prior to or during the time I owned the motor vehicle, it sustained damage for which the cost of
repair exceeded 50% of the fair market value before it became damaged.
Yes
No.
SIGNATURES
Date
Seller's signature
Date
Buyer's signature
The seller does not need to sign if Section 2 has been completed.
This form must be given to the buyer and surrendered to the County Treasurer when making application for title.
WARNING: A person who knowingly makes a false damage disclosure statement commits a fraudulent practice.
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