Dpsmv 1634 Form – Fill Out and Use This PDF

APPLICATION FOR A SALVAGE-RECONSTRUCTED MOTOR VEHICLE

LOUISIANA OFFICE OF MOTOR VEHICLES

	PO Box 64886, Baton Rouge, LA 70896
	www.expresslane.org
OWNER INFORMATION	PLEASE PRINT CLEARLY

Check one only: _____ Dealer _______ Individual

Name:____________________________________________Phone#______________________

Address:______________________________City:________________State:_____ZIP:________

(mailing)

Address:______________________________City:________________State:_____ZIP:________

(Business/residential - if different from mail address)

DL# _________________________	EIN#:
Signature:_______________________________________

VEHICLE INFORMATION

Vehicle Id Number (VIN):

YEAR:________ Make:_________ Model:______________ Color: __________________

Salvage Title#: (if available)_________________________________ State: __________________

REBUILDER INFORMATION (If different from owner)

Name:_____________________________________________Phone# ____________________

Address:______________________________City:________________State:_____ ZIP:________

(mailing)

Address:______________________________City:________________State:_____ZIP:________

(Business/residential - if different from mail address)
DL# _________________________	EIN#:
Signature:_______________________________________

STATEMENT OF REPAIRS (required by law) Check one only:

___ I have reconstructed or restored, or caused to be reconstructed or restored, the total loss salvage Motor vehicle to its operating condition which existed prior to the event which caused the salvage title to issue under (R.S.32:707) or the law of another state.

___The above described vehicle is a total loss salvage motor vehicle that was stolen and recovered.

I,________________________________________, swear under penalties of perjury that:

(Printed name of owner)

(i)The identification numbers of the restored or recovered vehicle and its parts have not been removed, destroyed, falsified, altered or defaced; and

(ii)the salvage title document attached to the application has not been forged, falsified, altered, or counterfeited; and

(iii)all information contained on the application and its attachments is true and correct to my knowledge.

DISCLOSURE OF SALVAGE/RECONSTRUCTED/WATER DAMAGED/HAIL-DAMAGED

I,________________________________________, swear under penalties of perjury that:

(Printed name of owner)

the title covering the above referenced vehicle, in accordance with Louisiana R.S. 32:706.1, has been branded:

______ Salvaged Vehicle

_____ Reconstructed Vehicle

In accordance with Louisiana R.S. 32:789, the undersigned confirm that the above referenced vehicle has sustained water damage to the following extent:

In accordance with Louisiana R.S. 32:781, the undersigned confirm that the above referenced vehicle has sustained water damage

to the following components: ______ Power Train ______ Computer______ Electrical System

In accordance with Louisiana R.S. 32:702(13), the undersigned confirm that the above referenced vehicle has sustained only cosmetic damage caused by hail, equivalent to seventy-five percent or more of its market value as a result of costs or repairs to items such

as windshield, windows, and rear glass; exterior paint and paint materials; and body damage such as dents.

_____ Hail-Damaged

Signed by_______________________________________under penalties of perjury this ____ day of

(signature of vehicle owner)

____________________, 20__.

False statements are punishable by fine, imprisonment or both under R.S. 32:730.

DPSMV 1634 (R0811)