Fillable Printable Mvr-4C
Fillable Printable Mvr-4C
Mvr-4C
VEHICLE SECTION
TITLE NUMBER YEAR MAKE VEHICLE IDENTIFICATION NUMBER STATE
OWNER SECTION
Owner 1 ID # ____________________ __________________________________________________________________________________________________________________
Full Legal Name of Owner 1 (First, Middle, Last, Suffix) or Company Name
Owner 2 ID # ____________________ __________________________________________________________________________________________________________________
Full Legal Name of Owner 2 (First, Middle, Last, Suffix) or Company Name
Residence Address (Individual) Business Address (Firm)
City and State Zip Code Tax County
Mail Address (if different from above)
INSURANCE COMPANY SECTION
Name of Insurance Company Name of Claims Person
Claim # Date of Payment Phone # of Claims Person
Street Address City N.C. Zip Code
The insurance company listed above has paid a total loss claim for the vehicle identified. In accordance with
North Carolina General Statute 20-109.1 and in cooperation with the Division of Motor Vehicles, the insur-
ance company has notified DMV that it did not acquire your vehicle as a result of the claims process and
that you, the vehicle owner, have retained the damaged vehicle (“salvage or water/flood vehicle”).
If you transfer title to this vehicle, you must disclose that this is a salvage or water/flood
vehicle.
I have read and understand the above.
________________________________________________
Signature of Owner
Date ______________ County __________________________________ State __________________________
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that
he or she voluntarily signed the foregoing document for the purpose stated therein and in the capacity indi-
cated: ______________________________________________________________________ (name(s) of principal(s)).
Notary Notary Printed
Signature ____________________________________________ or Typed Name ____________________________________
(SEAL) My Commission Expires ________________________
See Reverse Side
North Carolina Department of Transportation
DIVISION OF MOTOR VEHICLES
NOTIFICATION OF OWNER RETAINED VEHICLE
MVR-4C
(Rev. 2/06)
PLEASE COMPLETE IN FULL AND ATTACH COPY OF TITLE
G.S. 20-109.1. Surrender of titles to salvage vehicles.
(a) Option to Keep Title. — When a vehicle is damaged to the extent that it becomes a
salvage vehicle and the owner submits a claim for the damages to the insurer of the vehicle,
the insurer must determine whether the owner wants to keep the vehicle after payment of
the claim, the procedures in subsection (b) of this section apply. If the owner wants to keep
the vehicle after payment of the claim, the procedures in subsection (c) of this section apply.
(b) Transfer to Insurer. — If a salvage vehicle owner does not want to keep the vehicle,
the owner must assign the vehicle’s certificate of title to the insurer when the insurer pays
the claim. The insurer must send the assigned title to the Division within 10 days after
receiving it from the vehicle owner. The Division must then send the insurer a form to use
to transfer title to the vehicle from the insurer to a person who buys the vehicle from the
insurer. If the insurer sells the vehicle, the insurer must complete the form and give it to the
buyer. If the buyer rebuilds the vehicle, the buyer may apply for a new certificate of title to
the vehicle.
(c) Owner Keeps Vehicle. — If a salvage vehicle owner wants to keep the vehicle, the
insurer must give the owner an owner-retained salvage form. The owner must complete the
form and give it to the insurer when the insurer pays the claim. The owner’s signature on
the owner-retained salvage form must be notarized. The insurer must send the completed
form to the Division within 10 days after receiving it from the vehicle owner. The Division
must then note in its vehicle registration records that the vehicle listed on the form is a sal-
vage vehicle.
(d) Theft Claim on Salvage Vehicle. — An insurer that pays a theft loss claim on a vehi-
cle and, upon recovery of the vehicle, determines that the vehicle has been damaged to the
extent that it is a salvage vehicle must send the vehicle's certificate of title to the Division
within 10 days after making the determination. The Division and the insurer must then fol-
low the procedures set in subsection (b) of this section.
(e) Out-of-State Vehicle. — A person who acquires a salvage vehicle that is registered in
a state that does not require surrender of the vehicle’s certificate of title must send the title
to the Division within 10 days after the vehicle enters this State. The Division and the per-
son must then follow the procedures set in subsection (b) of this section.
(f) Sanctions. — Violation of this section is a Class 1 misdemeanor. In addition to this
criminal sanction, a person who violates this section is subject to a civil penalty of up to one
hundred dollars ($100.00), to be imposed in the discretion of the Commissioner.
G.S. 20-85 sets the fee for issuing a salvage certificate of title.
