Fillable Printable Damage Disclosure Statement
Fillable Printable Damage Disclosure Statement
Damage Disclosure Statement
MVR-181
(Rev. 12/2011)
DAMAGE DISCLOSURE STATEMENT
Questions 1 & 4 apply only to five (5) model years old and newer.
Alterations or erasures void this form.
NOTICE TO SELLER:
STATE LAW REQUIRES THAT EVERY SELLER DISCLOSE TO THE BUYER IF HE/SHE KNOWS THE INFORMATION LISTED BELOW.
FAILURE TO DO SO MAY RESULT IN CIVIL AND/OR CRIMINAL LIABILITY.
NOTICE TO BUYER:
RETAIN THIS INFORMATION.
STATE LAW REQUIRES YOU TO DISCLOSE SIMILAR DAMAGE INFORMATION WHEN YOU SELL OR TRANSFER TITLE TO THIS VEHICLE.
NOTICE TO BUYER:
RETAIN THIS INFORMATION. STATE LAW REQUIRES YOU TO DISCLOSE SIMILAR DAMAGE INFORMATION WHEN YOU SELL OR TRANSFER TITLE
TO THIS VEHICLE.
*See definitions on reverse side.
Year Make Body Style Vehicle Identification Number
1. Has this vehicle been damaged by collision or other occurrence to the extent that damages exceed 25% Yes
No
of its value at the time of the collision or other occurrence? (Applies to 5 Model Years old and newer)
If yes, list parts that were damaged. _______________________________________________________________
______________________________________________________________________________________________
2. Was this vehicle a salvage motor vehicle? (Applies to All Model Years) Yes
No
If yes, in which state was it titled? _________________________________________________________
3. Is this vehicle a flood vehicle? (Applies to All Model Years) Yes
No
4. Is this vehicle a recovered theft vehicle? (Applies to 5 Model Years old and newer) Yes
No
If yes, list parts that were damaged. ______________________________________________________________
5. Has this vehicle been reconstructed? (Applies to All Model Years) Yes
No
As the Seller, I declare that the above information is true to the best of my knowledge.
SELLER’S SIGNATURE: _________________________________________ DATE: ___________________________________________________________
SELLER’S ADDRESS: ____________________________________________________________________________________________________________________
BUYER’S ACKNOWLEDGEMENT AND SIGNATURE: ___________________________________________________________________________________________
Damage Disclosure Definitions
Five (5) Model Years - The term “five model years” shall be calculated by counting the model year of the vehicle’s manufacture as the first model year
and the current calendar year as the final model year.
Flood Vehicle - A motor vehicle that has been submerged or partially submerged in water in the extent that damage to the body, engine,
transmission, or differential has occurred.
Non-U.S.A. Vehicle - A motor vehicle manufactured outside of the United States and not intended by the manufacturer for sale in the United States.
Reconstructed Vehicle - A motor vehicle of a type required to be registered hereunder that has been materially altered from original construction
due to removal, addition or substitution of new or used essential parts; and includes glider kits and custom assembled vehicles.
Salvage Motor Vehicle - Any motor vehicle damaged by collision or other occurrence to the extent that the cost of repairs to the vehicle and
rendering the vehicle safe for use on the public streets and highways would exceed seventy-five percent (75%) of its fair retail market value, whether
or not the motor vehicle has been declared a total loss by an insurer. Repairs shall include the cost of parts and labor; or a vehicle for which an
insurance company has paid a claim that exceeds 75% of the fair market retail value. Fair market retail values shall be as found in the NADA Pricing
Guide Book or other publications approved by the Commissioner.
Salvage Rebuilt Vehicle - A salvage vehicle that has been rebuilt for title and registration.
Junk Vehicle - A motor vehicle which is incapable of operation or use upon the highways and has no resale value except as a source of parts or scrap,
and shall not be titled or registered.
