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Utah State Tax Commission
TC-802N Rev. 5/02

Notice Of Requirement To Obtain Salvage Title
Division of Motor Vehicles · 210 North 1950 West · Salt Lake City, Utah 84134 Motor Vehicle Information (Print or type legibly) Make Model VIN

Type

Body style

License number

State

Owner name

Address

City

State

ZIP code

Insurance Company Certification Name of insurance company

This is to certify that on the __________ day of ________________, 20____, that our insurance company named above, satisfied a total collision loss claim on the motor vehicle described above and the owner elected to retain possession of the salvage vehicle. As required by Utah Code 41-1a-1005, this is to certify that the above named owner has been notified of the requirement to obtain a salvage certificate of title on the vehicle identified above.
Insurance company's signature X Owner Acknowledgement Title Date

This is to certify that on the __________ day of ________________, 20____, I was notified by the above name insurance company of my obligation to obtain a salvage title within ten days of settlement of my claim, and that I have received a copy of the notice as required by Utah Code 41-1a-1005.
Owner's signature X
WHITE - Tax Commission YELLOW - Owner PINK - Insurance Company

Date