JUNK FRAME STATEMENT MV2731 4/2014 WI Admin. Code Trans 149 & 305.23

Wisconsin Department of Transportation (WisDOT) http://wisconsindot.gov

I certify that the vehicle frame on the junked vehicle listed below has not been damaged. The frame is sound and able to be used to repair a vehicle as of the date this form is signed.

I also understand that any person who knowingly makes a false statement to the Wisconsin Department of Transportation in an application for title is guilty of a Class H Felony under s.342.06(02) Wisconsin Stats.

X X (Supplier Signature) (Date – m/d/yyyy) (Buyer/Authorized Agent Signature) (Date – m/d/yyyy)

This form must be submitted with the repaired salvage vehicle application to the Wisconsin Salvage Vehicle Inspector.

FRAME SUPPLIER or FRAME SELLER If not typed, complete form using BLUE or BLACK ink. Name (first, middle initial, last)

Dealer or Salvage Dealer Number

Address, City, State, ZIP Code

FRAME FROM VEHICLE Year

Make

Model

Vehicle Identification Number (VIN)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19