TOTAL LOSS STATEMENT MOTOR VEHICLE DIVISION North …
TOTAL LOSS STATEMENT
North Dakota Department of Transportation, Motor Vehicle
SFN 53386 (4-2020)
THIS WILL CERTIFY THAT Owner
Mailing Address
City
Received compensation for the following vehicle:
Year
Make
Vehicle Identification Number
Which was a total loss as a result of an incident/crash occurring on: Month
Day
Claim Number (Required)
Date of Payment (Required)
MOTOR VEHICLE DIVISION ND DEPT OF TRANSPORTATION 608 E BOULEVEARD AVE BISMARCK ND 58505-0780 Telephone (701)328-2725 Website:
Telephone Number
State
ZIP Code
Year
NOTE: Credit can be claimed no more than three years from date compensation was received.
TOTAL LOSS PAID TO CUSTOMER PLUS DEDUCTIBLE
OWNER RETAINED SALVAGE?
YES
NO
NOTE: If additional monies (ex: Excise Tax) paid to customer, please attach itemization.
Name of Insurance Company Address City Telephone Number
State
ZIP Code
FOR MVD USE ONLY NOTE: You must retain this form to obtain future credit. CREDIT USED
CREDIT REMAINING
CREDIT MUST BE USED BY
APPROVED BY
Last 8 of VIN
Title Number
CREDIT USED CREDIT REMAINING CREDIT MUST BE USED BY APPROVED BY
Last 8 of VIN
Title Number
CREDIT USED CREDIT REMAINING CREDIT MUST BE USED BY APPROVED BY
Last 8 of VIN
Title Number
Name (Type or Print)
Signature of Authorized Agent (sign before a Notary Public or Authorized Officer)
State of County of
Acknowledgement
Signed and sworn to (or affirmed) before me on this day
(month, day, year)
Name of Notary Public or other Authorized Officer (Type or Print)
Signature of Notary Public or other Authorized Officer
Commission Expiration Date (if not listed on stamp)
Affix Notary Stamp
................
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