Fillable Printable Rtb 2006 034 Attach1

Rtb 2006 034 Attach1

VTR-61

(Rev. 4/2006)

DHT # 142251

REBUILT AFFIDAVIT

(TYPE OR PRINT INFORMATION)

INSTRUCTIONS

• All information on the front of this form must be complete

• The vehicle owner or their authorized agent must complete the Owner Statement bel o w.

• The person who repaired, rebuilt, reconstructed or assembled the vehicle must complete the information on the

reverse si de if component par ts were used.

• If rebuilt by the owner, the owner must complete both

the Owner Statement and the Rebuilder Certification on the

reverse side.

• The Rebuilder Certification must be notarized.

VEHICLE INFORMATION

YEAR

MAKE

MODEL

BODY STYLE

VEHICLE IDENTIFICATION NUMBER

DOCUMENT/TITLE NUMBER (IF APPLICABLE)

INSPECTION INFORMATION

AN AUTHORIZED INSPECTION STATION MUST

INSPECT THE VEHICLE AFTER

IT HAS BEEN REBUILT

(not required for Title Only transactions)

(REBUILT ) VEHICLE INSPECTION STICKER NUMBER

EXP. DATE

EXPLANATION OF REPAIRS

Explanation by rebuilder (owner or pers on who rebuilt the vehicl e) as to what was done in relation to the assembling, rebuilding, altering, etc., of the

vehicle f or which title is sought:

Information on the reverse side must also be completed if component parts have been used.

OWNER STATEMENT

This statement is to certify that:

• I am the legal and rightful owner of the vehicle described above.

• The vehicle is rebuilt, repaired, reconstructed or assembled.

• The vehicle identification number disclosed herein is the same as the vehicle identification number affixed to the

motor vehicle.

Owner’s Name Owner’s Signature

Mailing Address Date

City, State, Zip

WARNING! TRANSPORTATION CODE §501. 155 PROVIDES THAT FALSIFYING INFORMATION ON ANY REQUIRED DOCUMENT

IS A THIRD-DEGREE FELONY.

IF THE VEHICLE HAS BEEN REBUILT, RECONSTRUCTED OR ASSEMBLED FROM COMPONENT PARTS, COMPLETE THE FOLLOWING INFORMATION.

COMPONENT PART ORIGIN OF COMPONENT PARTS/PURCHASED FROM:

Attach evi dence of ownership

(bill of sale and/or title)

NAME ADDRESS CITY, STATE, ZIP

(REQUIRED)

COMPONENT PART NUMBER

ENGINE

FRAME

BODY

Î SPECIFY LOCATION OF COMPONENT PARTS REPLACED: RIGHT (RT) LEFT (L) FRONT (F) REAR (R) RIGHT FRONT (RT F) LEFT FRONT (L F) RIGHT REAR (RT R) LEFT REAR (L R)

COMPONENT PART ORIGIN OF COMPONENT PARTS/PURCHASED FROM:

Submit any bills of s a l e for

component parts (if avail abl e)

NAME ADDRESS CITY, STATE, ZIP

(IF AVAILABLE)

COMPONENT PART NUMBER

TRANSMISSION

FENDER(S) Î

HOOD

DOOR(S) Î

BUMPER(S) Î

QUARTER PANEL(S) Î

TAILGATE/HATCHBACK/DECK LID

PICKUP CARGO BOX (truck, less

than one ton)

TRUCK CAB

ROOF OR FLOOR PAN (passenger

vehicle, if separate from body)

REBUILDER CERTIFICATION

Before me, the undersigned authority perso nally appeared the affiant whose name is subscribed her eto and being duly sworn, deposes and upon oat h states that the affiant:

• rebuil t, repaired, reconstructed or assembled the vehicle d escribed above.

• purchased or came into possession of all the component p arts li sted above in a legal and lawful manner and in acc ordance with the provi sions of Transportation Code,

Chapter 501.

Rebuilder’s Name

Subscribed and sworn to before me this

day of

, year

Mailing Address

NOTARY SEAL

City, State, Zip

Rebuilder’s Signature

COUNTY, TEXAS

NOTARY PUBLIC SIGNATURE