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WAiHING011 SfAHC UEPARTMENT OF
LICENSING Junk Vehicle Affidavit
Law enforcemeinto fficers and authorized junk vehicle inspectors use this form to certify that an abandoned vehicle qua - lifies
as a junk vehicle. Landowners use this form to notify the last owner (if known) of the vehicle, to certify that the vehicle Owner
was notified and has not redeemed the vehicle, and as an owner- hi
s P document for retitling, selling, Or disposing of the
vehicle. Contact a law enforcement cagency or an authorized junk. vehicle inspeGtor to arrange for inspectlon of the vehicle.
To qualify as
a junk vehicle, the vehicle must meet three of the following conditions:
Must be at least three years old
Must be extensively damaged
• Must be apparently inoperable
• Must have a fair market value equal only to the approximate value of the scrap of the vehicle
Law enforcement officiLx-r or authorized junk inspector
Check to indicate damaged or missing parts -
A
Engihe
171
Rear bumpe-Ar
B
Transmission
A
J
Grill
Front xde
K
K
Hood
Tr nk lid
Rear axle
L
L
Right front fender
E
-,a
R-ght front s-lt
A
Left front fender
F
Left front seat
__Ji�
Win' dshi-ld
F-1 G
I ear
El o
Right front door
i
P n* burnoer
I
D P
Right re-, r door
I h3v Z, !-, d -s rib -c-1 a, bo v --i a i i id cert i fit th 3 f it t-71 jafji ic.i e
pn-taf:l tn'3 viehicle,
a iun�- venhic!e
X
L
r 'I
Q
Right rear fendYr
R
Left front door
Left, rear door
T.
L A- ft rear rfe P d -- r
U
ear window
V
Tr nk lid
D
Vehicle owner(s) rights
You have the right to arrange to remove Your vehicle from the property where it is located within 15 days after the date
-in -a n
M ol yourvehicle, the ol,�.iner ^I -r - , 0 �J I I
do r pose of if ^I ffay,-i,
this formlNas mailed to you. If you d of rent foul) V 11%, %11 --,1 %..,1 flhe.. property may depose
Affidavit of Sal --1-3., to be used as an o�j%inership docurnent to *sell or retitle it.
Landowner
To request an abandoned junk vehicle inspection you 'Must be the legal owner or person with possession or control of, or the
public official with jurisdiction over, the property wherea the vehicle described on page one of this form is located.
Mail a copy of this entire form to both the registered and legal owner(s) of the vehicle described on page 1, or, if no
owner inlorma
I tion was found, check the proper box below,
Chp-*(-,k ona:
F-1 I mailed a copy of this Junk Vehicle Disposal Affidavit to the registered and legal owner(s) of the vehicle more than
15 days ago and the owner(s) has not redeemed the vehicle.
C� No registered or legal owner(s) information could be found.
I certify under penalty of perjL[r'y under the latills of the state of Waz-hington that the foregoing is true a-nd correct.
X
Date and plach- Lando�,mer signature�-��
If the vehicle remains unclaimed more than 15 days afterou have mailed n6tification to the oWnet r
y (8) o' 'if no'oWn6r
information could be found:
It Sign the, Affidavit of Sale below for use as an ownership document.
You may make arrangements to remove the vehicle.
You are entitled to recover all costs of the removal of the junk vehicle from the vehicle owner.
Affid.avit of Sale --Complete this section for, use as an ownership document when you retitle, sell, or dispose, of the vehicle
Purchaser name
Purchaser street address
city
State
ZIP �2_3
X
Landowner signati
Date
Notary or agent
6 r
N fit Statile of
s1k J VA&
County Of
OVA"
,r tt-Ea
k�111 ;4NN 0 U sted baforz m
/, Sign,ad oa on /0 -3 -2-
byin
Ari°CIO -:7 4 OfT A
ri M4, of p-rs
p 3on ign d f sale
lop 1408k P)
(P (I B 0
ignatur an
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tAcent
10, 10 O*V A�
Sk, N,
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AV% AL I I &A Q^11r7
Mpftd 70%% W%OFM&-
U84A, Print or $_
NO
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and Y A ®MILT E I EXR 10,26
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Not\_:,rVA -ant W,19
Denler or c; n jlofeice number or notari expiration data
If you intend to operate this after completion of repairs, this form and the vehicle'Dust be., taken to the Washington
Stet? Patro! (\I�JSP) for inspection. A VV`Q inspection form must, be included with your title application,
I -, I I separate _%. � inspection 1 Za 1 1;;:7 CA
R W 4.6.555.010: 4r 8. 55 15). _9 3 0