OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES UNCLAIMED MOTOR VEHICLE AFFIDAVIT Section 4505.101 of the Ohio Revised Code (To be Completed by Repair Garage or Storage Facility Only) WARNING: Applicant giving false information in the execution of this affidavit is subject to prosecution under Section 2921.13 of the Ohio Revised Code. Punishable by up to a one thousand ($1,000.00) dollar fine and/or up to six (6) months in jail. FEE $5.00 Make check payable to: Ohio Treasurer Kevin L. Boyce This is to certify that the following vehicle has been abandoned by the owner (not due to law enforcement agency storage order) and left unclaimed for more than fifteen (15) days at the following location. Affidavit must be filed in same county as where repair garage or storage facility is located. BMV USE ONLY ACCOUNT CODE NUMBER THE BELOW LISTED SECTION MUST BE COMPLETED BEFORE SUBMITTING TO THE BUREAU OF MOTOR VEHICLES. NAME OF BUSINESS VENDOR/TAX ID NUMBER DATE OF APPLICATION DATE VEHICLE RECEIVED STATE ADDRESS CITY CUSTODIAN’S PHONE NUMBER NAME OF LAW ENFORCEMENT AGENCY CONTACTED (POSTED PARKING ONLY) VIN NUMBER VEHICLE YEAR MAKE PLATE STATE LOCATION VEHICLE TOWED FROM (POSTED PARKING ONLY) POSTED PARKING NO YES PLATE NUMBER PLATE YEAR ZIP CODE MODEL BODY STYLE LIST THE EXTENT OF PHYSICAL DAMAGES. A. Wholesale value of vehicle regardless of condition, if wholesale value is not available, use average trade-in value as of this date: NADA B. Estimated cost of repairs to restore vehicle to wholesale value. C. Actual expenses incurred; add totals. Storage Tow Repair (Contract Only) Admin Costs D. Total Deductions (Add lines B and C) E. Value of vehicle, less deductions (Subtract line D from A). If more than $2,499.99 this form cannot be used. This amount paid to the Clerk of Courts when title is issued to custodian. BUREAU USE ONLY NAME OF OWNER(S) TITLE # OWNER(S) ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE NAME OF LIEN HOLDER LIEN HOLDER’S ADDRESS *IMPORTANT NOTICE TO CUSTODIAN* THE FOLLOWING IS NOT TO BE COMPLETED UNTIL RETURNED BY REGISTRAR The custodian hereby certifies compliance with all provisions of Section 4505.101 of the Ohio Revised Code. This includes notifying the owner, mortgagee, or lien holder by Certified Mail (return receipt requested), of the repair/storage charges. Also, include where the vehicle is located and that it must be claimed within fifteen (15) days of the mailing date of the notice, “(has received the signed receipt from the Certified Mail or has been notified that the delivery was not possible)” or ownership will be forfeited and mortgage or lien shall be invalid. The custodian further certifies that the vehicle has remained unclaimed following notification and that a search of the Ohio Bureau of Motor Vehicles records has been made for outstanding liens on the vehicle before executing the unclaimed motor vehicle affidavit. SIGNATURE OF CUSTODIAN X CUSTODIAN ADDRESS Sworn to and subscribed in my presence this CITY day of , MAIL ITEMS TO: OHIO BUREAU OF MOTOR VEHICLES Attn: D.R.A.S.S./S.A.O. P.O. Box 16520 Columbus, Ohio 43216-6520 STATE . ZIP CODE , My commission expires on X NOTARY PUBLIC (SEAL) copy – Clerk of Courts copy – Custodian Employee Initials BMV 4202 6/10 American LegalNet, Inc. www.FormsWorkFlow.com .