SIGNATURE OF INSURANCE COMPANY REPRESENTATIVE NO COPIES OR STAMPSXDATEVIN NoDaytime Phone AddressWeight orStyle of BodyYearOdometer Reading STREET ADDESSPASSENGER VEHICLETRUCKS GVWC ID: 887905
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*This form must be accompanied by the owner’s title and the required $22.50 fee.ANY ALTERATIONS OR ERASURES WILL VOID THIS FORM. SIGNATURE OF INSURANCE COMPANY REPRESENTATIVE (NO COPIES OR STAMPS) (X)DATE VIN No.Daytime Phone Address Weight or Style of Body YearOdometer Reading( - STREET ADDESSPASSENGER VEHICLE TRUCKS GVWCITYSTATEZIPVehicle Information Insurance Company Declaration & Certi cation The above vehicle has been declared to be a total loss, but the damage is exclusively cosmetic and no repair is necessary in orlegally and safely operate the motor vehicle on hte roads and highways of this state. I hereby certify under penalty of nes and/or imprisonment, that the statements made herein are correct to the best of my knowland belief.Indicate Damage: 1-800-642-9066www.dv.v.gvDMV-SV-5REV 6/17 Certi cate of Cosmetic Total Loss