New York State Department of Motor Vehicles MV-901D (5/11) GARAGEMAN’S CERTIFICATION AND BILL OF SALE FOR VEHICLES WORTH LESS THAN $500.00 DISPOSAL OF LAWFULLY TOWED AND/OR STORED VEHICLES UNDER LIEN LAW, SECTION 202 (This form is also available to download from the DMV website: www.dmv.ny.gov) NOTICE: THE VEHICLE DESCRIBED HEREIN MAY NEVER BE TITLED AGAIN. IT MUST BE DISMANTLED OR SCRAPPED. AFTER COMPLETION, PLEASE SUBMIT THIS FORM TO THE VEHICLE DISMANTLER OR SCRAP PROCESSOR. IMPORTANT INFORMATION REGARDING THESE REQUIREMENTS CAN BE FOUND ON FORM MV-901DI. To knowingly make a false statement or conceal a material fact in this statement is a criminal offense punishable under Section 210.45 of the Penal Law, and Section 392 of the Vehicle and Traffic Law. I, the undersigned GARAGEMAN, certify under penalty of perjury as follows (if signing as an authorized representative of a business organization, such as a corporation, I certify that I possess the personal knowledge to make such certification and I am duly authorized to so certify on behalf of the business): (1) the undersigned currently holds a valid, perfected Garageman’s Lien on the motor vehicle described herein; (2) such lien represents accrued and unpaid towing and/or storage charges which remain unpaid to date; (3) the subject vehicle currently has a wholesale value of less than $500, as indicated by the nationally recognized source checked below; and (4) the undersigned sold this vehicle to the vehicle dismantler or scrap processor named herein. 1. Description of Vehicle (a statement of acquisition must be attached [see MV-901DI]): Year: _______ Make: ________________________ Model: ________________________ Plate Number: ___________________ State: ________ Vehicle Identification Number: (attach photo or tracing) ____________________________________________ 2. Source of Wholesale Value relied upon by the undersigned: £ NADA £ Kelly Blue Book Wholesale Value of Vehicle: $ _________________________ £ Other (please describe)_________________________________________ 3. Garageman (a copy of proof of business must be attached [see MV-901DI]): Business Address:______________________________________________________ Apt./STE# ____________ Government Issued ID for person submitting this form (copy must be attached): City:__________________________________________ No.:_________________________ Business Name:___________________________________________________ Facility # ___________________ 4. State: ___________ Zip Code ______________ Vehicle Dismantler or Scrap Processor: Business Address:_______________________________________________________ Apt./STE# ____________ Government Issued ID for representative of vehicle dismantler or scrap processor (copy must be attached): City:__________________________________________ No.:_________________________ Business Name:___________________________________________________ Facility # ___________________ 5. State: ___________ Zip Code_______________ Prior Owner (a copy of verification of prior owner and other lienholders must be attached): Name: ___________________________________________________________________________________________________________________ Street Address:______________________________________ Apt./STE# ______City:__________________________ State: ______ Zip Code___________ 6. Lienholders (Attach additional sheet, if necessary) Business Name:_______________________________________________ Business Name:________________________________________________ Business Business Address:______________________________________ Apt./STE# ______ Address:______________________________________ Apt./STE# ______ City:__________________________ State: ______ Zip Code__________ City:__________________________ State: ______ Zip Code__________ 7. Service of Notice and Towing and/or Storage Information (a copy of the Notice of Lien and Sale, and a copy of receipt for mailing must be attached [see MV-901DI]): Date of Service of Notice to Owner: _______/_______/_______ Date of Service of Notice to Lienholder(s): ______/_______/_______ 8. Date Vehicle was Towed :(Towing authorization must be attached) 9. Date Storage Began: 10 Date of Sale: ______ / _______ / ________ ______ / _______ / ________ ______ / _______ / ________ I further certify that: the Date of Sale is not (a) prior to thirty days after the date on which Service of Notice was mailed, or (b) prior to sixty days after the date of the initial tow, whichever is later; no action was brought under Section 201-a of the Lien Law, or, an action was brought and the determination was in my (our) favor; and the required Notice of Lien was sent to owner(s) and lienholder(s). Proof of certified mailing is attached. ç GARAGEMAN’S/REPRESENTATIVE’S NAME - Print GARAGEMAN’S/REPRESENTATIVE’S SIGNATURE - Please sign name in full GARAGEMAN’S/REPRESENTATIVE’S TITLE DATE American LegalNet, Inc. www.FormsWorkFlow.com