Mva Vr 028 Form – Fill Out and Use This PDF

q Check here if applying for a

This application is to be used by the vehicle owner, when a vehicle is sold as salvage pursuant to

Certificate # (MVA Use Only)

Salvage Certificate

§13-506 and §13-507 or acquired as an abandoned vehicle from a police auction pursuant to

§25-207 of the Maryland Vehicle Law.

For reference refer to back of this form.

q Check here for

Maryland Vehicle Law §13-506.1 requires the insurance company to promptly notify the Motor Vehicle Administration of vehicles that

Owner Retention

have been settled as a total loss and are being retained by the owner.

If the applicant checks boxes 1 or 6, a Corrected Certificate of Title bearing the appropriate brand will be issued. The fee will be $50.00.

If the applicant checks box 3, a Salvage Certificate bearing the appropriate brand will be issued. The fee will be $20.00.

NOTE: Boxes 4, 5, 8 and 9 are not applicable for owner retention.

Applicant’s Full Name

Date of Birth

FEIN #

Driver’s License Number

Co-Applicant’s Full Name

Date of Birth

Driver’s License Number

Street Address

City or Town

State

Zip Code

Description of Salvage Vehicle:

Year

Make

Model

Body Style

Vehicle Identification Number

Gross Vehicle Weight

Out of State Title #

Maryland Title #

Applicant Is:

For:

Reason For Duplicate:

Purchase Price $ ___________________

Title Service # ______________________

Certificate of Origin? q Yes

q No

q Insurance Company

q Original

q Lost

Odometer Reading ________________________ (No Tenths)

q Vehicle Owner

q Stolen

q Automotive Dismantler & Recycler

q Duplicate

q Mutilated

Dealer # ___________________________

Scrap Processor #__________________

q 1. The mileage stated is in excess of its mechanical limits.

q Scrap Processor

q Other

q 2. The odometer reading is not the actual mileage.

Auctioneer # _______________________

AD&R # ____________________________

Warning - Odometer Discrepancy

To be completed by applicant:

q 1.

Damage is greater than 75% of the fair market value and repairable.

q 2.

Damage is 75% or less of fair market value.

q 3.

The vehicle is not rebuildable, will only be used for parts, and is not to be retitled.

q 4.

Abandoned vehicle or acquired in the normal business of an Automotive Dismantler & Recycler.

q 5.

Recovered Stolen with damage 75% or less of the fair market value will be issued a Salvage Certificate branded “Recovered Stolen”.

q 6.

Flood damage

q 7.

Damage is greater than 75% of the fair market value and the damage to the vehicle is cosmetic only. (obsolete as of October 1, 2010)

q 8.

Recovered Stolen with damage 75% or less than the fair market value and requesting a Certificate of Title - Complete an Application for Certificate of Title (VR-005).

q 9.

Stolen

I certify under penalty of perjury, that the statements herein are true and correct to the best of my knowledge, information and belief.

Signature of Applicant(s) or Authorized Agent: ___________________________________________________________________________________

Date: _______________________________________________________________________________

[If a company, must be signed by an authorized agent (capacity)]

Printed Name of Applicant(s): ___________________________________________________________________________________________________

Date: _______________________________________________________________________________

Business Name: _____________________________________________________________________ FEIN #___________________________________

Date: _________________________________________________________________________

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