FRAUDULENT OR LATE FORMS MAY RESULT IN CRIMINAL PROSECUTION
INCOMPLETE FORMS WILL BE RETURNED TO SENDER FOR CORRECTION PRIOR TO PROCESSING
Date

Make
Year
Serial Number/VIN
Date Vehicle Left

Lic. Plate No.
Year
State

County (if shown on license)
Body

Approximate value $
Vehicle Left For
Parking Repairs Storage Other
Explain
Location of vehicle (place stored)
Address
City
State

Zip
Telephone No.
Name and address of the person authorizing your Firm to tow, store, and/or make repairs: (Required or explain)
Name or Explanation
Address
City
State

Zip
Any evidence in vehicle to assist in locating owner or in tracing
Is vehicle in running condition?

Wrecked?

Remarks
I certify that the above information is true and correct.
Validating Fields
Validating VIN
Submitting Form
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