OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES 81&/$,0(' 02725 9(+,&/( $)),'$9,7 6HFWLRQ  RI WKH 2KLR 5HYLVHG &RGH (To be Completed by Repair Garage or Storage Facility Only) :$51,1* 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. )(( 85 Make check payable to: Ohio Treasurer Kevin L. Boyce %09 86( 21/< 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: NAME OF CUSTODIAN (BUSINESS) CUSTODIAN BUSINESS PHONE ACCOUNT CODE NUMBER DATE OF APPLICATION DATE VEHICLE RECEIVED VENDOR NUMBER ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE NAME OF VEHICLE OWNER(S) OWNER(S) ADDRESS VEHICLE YEAR MAKE MODEL VIN BODY STYLE STATE LICENSE PLATE A. Wholesale value of vehicle regardless of condition, as of this date: (Check One) NADA YEAR RED BOOK $0.00 $0.00 B. Estimate cost of repairs to restore vehicle to wholesale value ……………………………………………………………… Tow Storage Repair Other C. Actual Expenses incurred; add totals $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D. Total Deductions: (Add lines B and C) ………………………………………………………………………………………… E. Value of vehicle, less deductions: (Subtract line D from line A) If more than $2500.00 this form cannot be used. This amount paid to Clerk of Courts when title is issued to Custodian ……………………………………………………….. $0.00 List extent of physical damage (if any) %85($8 86( 21/< NAME OF OWNER(S) TITLE # OWNER(S) ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE NAME OF LIEN HOLDER LIEN HOLDER’S ADDRESS ,03257$17 127,&( 72 &8672',$1 7+( )2//2:,1* ,6 127 72 %( &203/(7(' 817,/ 5(7851(' %< 5(*,675$5 The custodian hereby certifies compliance with all provisions of Section 4505.101 of the Ohio Revised Code. This includes notifying the owner, mortgagee or lien holder by Certified Mail (return receipt requested), of the repair/storage charges. Also, where the vehicle is located and that it must be claimed within fifteen (15) day of the mailing date of the notice, “(has received the signed receipt from the certified mail or has been notified that the delivery was not possible)” or ownership will be forfeited and mortgage or lien shall be invalid. The custodian further certifies that the vehicle has remained unclaimed following notification and that a search of the Ohio Bureau of Motor Vehicles records has been made for outstanding liens on the vehicle before executing the unclaimed motor vehicle affidavit. SIGNATURE OF CUSTODIAN ; CUSTODIAN ADDRESS Sworn to and subscribed in my presence this CITY , day of ZIP CODE , My commission expires on ; 0$,/ ,7(06 72 OHIO BUREAU OF MOTOR VEHICLES Attn: D.R.A.T.S.S./TACS P.O. Box 16520 Columbus, Ohio 43216-6520 STATE NOTARY PUBLIC 6($/ copy – Clerk of Courts copy – Custodian Employee Initials BMV 3702 10/09 American LegalNet, Inc. www.FormsWorkFlow.com