Free 49891.FH11 - Indiana

SALVAGE TITLE AFFIDAVIT
State Form 49891 (9-00)

) ) SS: COUNTY OF _______________________ ) STATE OF INDIANA

INSURANCE COMPANY / OWNER NAME AND AGENT NAME

ADDRESS

Deposes and says upon his (or her) oath that: Applicant wishes to apply for a SALVAGE TITLE for the vehicle described herein as: Year _______________ Make___________________________________________ and ID# _____________________________________________________________

This vehicle meets the salvage title requirements as stated in Indiana Code 9-22-3-11: ... (a) This section applies to the following persons: (1) An insurance company or other person that has acquired a wrecked or damaged motor vehicle, motorcycle, semitrailer, or recreational vehicle that meets at least one (1) of the criteria set forth in section 3 of this chapter and the ownership of which is not evidenced by a certificate of salvage title. (2) An insurance company that has made and paid an agreed settlement for the loss of a stolen motor vehicle, motorcycle, semitrailer, or recreational vehicle.......... I swear or affirm that the information I have entered on this form is correct. I understand that making a false statement on this form may constitute the crime of perjury.
Signature Date (month, day, year)