OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES UNCLAIMED MOTOR VEHICLE AFFIDAVIT Section 4505.101 of the Ohio Revised Code (R.C.) VEHICLE VALUE: Must be less than $3500 to use this affidavit. Wholesale Value (as provided in a vehicle valuation guide recognized by the motor vehicle industry) Estimated cost of repairs to restore vehicle to wholesale value Cost of agreed upon repairs VEHICLE VALUE (amount paid to the clerk) (A) $ (B) $ (C) $ (A) ­ (B) ­ (C) = $ A search of the records of the Bureau of Motor Vehicles has been made to identify any owner or lienholder. (REQUIRED) VEHICLE IDENTIFICATION NUMBER (VIN) YEAR MAKE MODEL EXACT BUSINESS NAME BUSINESS STREET ADDRESS CITY BUSINESS OWNER / AUTHORIZED AGENT NAME P.O. BOX STATE BUSINESS TELEPHONE COUNTY ZIP CODE ALTERNATIVE TELEPHONE CHECK ONE BOX IN SECTION A OR B AND COMPLETE REQUIRED INFORMATION SECTION A for Repair Garage / Place of Storage (with an agreement) Repair garage with a repair agreement DATE CERTIFIED MAIL SENT Place of Storage with a storage agreement DATE OF COMPLETED REPAIR / TERM OF STORAGE SECTION B for Towing Service / Storage Facility under authority of section R.C. 4513.601 (must include copies of notices and certified returned mail receipts) Towing Service that removed the vehicle under division Storage Facility where a for-hire motor carrier delivered a (B) of section R.C. 4513.601. motor vehicle under section R.C. 4513.601. DATE OF REMOVAL DATE OF 2ND NOTICE (30 days after 1st notice) DATE OF 1ST NOTICE (within 5 business days of removal date) DATE OF 3RD NOTICE (45 days after 1st notice) Unless otherwise specified, days are equal to calendar days. By completing this form, I am hereby affirming that ALL of the requirements of R.C. Section 4505.101 and / or 4513.601 have been met. I also am affirming that all the information contained on this form is true and accurate to the best of my knowledge and belief. I understand that providing false information may constitute a criminal offense of falsification under R.C. 2921.13, a misdemeanor of the first degree. SIGNATURE OF BUSINESS OWNER / AUTHORIZED AGENT DATE OF APPLICATION X NOTARY Subscribed and sworn to before me this county of day of State of Ohio. , in the (SEAL) My commission expires X SIGNATURE Additional documentation may be required upon request of the Clerk of Courts. BMV 4202 2/15 [760-0124] American LegalNet, Inc. www.FormsWorkFlow.com