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Get il disclosure statement 2016-2024

Cyberdriveillinois. com This form may be completed by the registered owner in possession of a vehicle at the time of the natural disaster or a vehicle dealer capable of producing documentation attesting to the location of a vehicle at the time of the natural disaster. Print Reset Secretary of State Natural Disaster Disclosure Statement Vehicle Services Department 501 S* Second St* Rm* 009 Springfield IL 62756 www. Vehicle Information Year Make Where did you purchase this vehicle VIN The undersigned registered owner at the time of the natural disaster or the dealer/owner at the time of the natural disaster confirms that the vehicle stated above Was not in a natural disaster area* Sustained NO physical damage. Sustained NO water damage. Other Sustained minor water damage. Under penalty of perjury the registered owner/Dealer Agent affirms that the information provided in this of State to issue an Illinois clean title. Signature of Registered Owner/Dealer Agent Name of Registered Owner/Dealer print Date Address State of County of Signed and attested before me on Signature of Notary Public Complete when applicable or settlement has been made with the insured as follows Claim was initiated but closed with no settlement being made. Settlement was made vehicle sustained minor damages or less than total loss attach proof of loss statement. Claim was closed at the request of the insured with no settlement. Insured did not have appropriate coverage liability only. Insurance Company Claim Name of Authorized Agent/Representative print Signature of Authorized Agent/Representative Daytime Phone Number Upon issuance of an unbranded Certificate of Title the Office of the Secretary of State or its authorized agents assumes no responsibility or liability for any vehicle found to have actually sustained damages. Vehicle Information Year Make Where did you purchase this vehicle VIN The undersigned registered owner at the time of the natural disaster or the dealer/owner at the time of the natural disaster confirms that the vehicle stated above Was not in a natural disaster area* Sustained NO physical damage. Sustained NO water damage. Other Sustained minor water damage. Under penalty of perjury the registered owner/Dealer Agent affirms that the information provided in this of State to issue an Illinois clean title. Sustained NO water damage. Other Sustained minor water damage. Under penalty of perjury the registered owner/Dealer Agent affirms that the information provided in this of State to issue an Illinois clean title. Signature of Registered Owner/Dealer Agent Name of Registered Owner/Dealer print Date Address State of County of Signed and attested before me on Signature of Notary Public Complete when applicable or settlement has been made with the insured as follows Claim was initiated but closed with no settlement being made. Signature of Registered Owner/Dealer Agent Name of Registered Owner/Dealer print Date Address State of County of Signed and attested before me on Signature of Notary Public Complete when applicable or settlement has been made with the insured as follows Claim was initiated but closed with no settlement being made. Settlement was made vehicle sustained minor damages or less than total loss attach proof of loss statement. .

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