Fillable Printable Rtb 2011 048 Attachment3
Fillable Printable Rtb 2011 048 Attachment3
Rtb 2011 048 Attachment3
VTR-331-A
(09/11)
Page 1 of 2
Insurance Company Statement of Facts
This form may not be used for any vehicle claim paid prior to September 1, 2011
PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS APPLICATION.
This statement must be submitted to the county tax office as an application for an original Texas Certificate of Title without
registration to:
1) county tax office where the insurance company (title applicant) is located;
2) county tax office where the previous owner resided (seller) resided; or
3) county tax office where the lienholder (if applicable) is located.
APPLICANT INFORMATION– Type or print only
Day Phone Name of Insurance Company
E-mail (optional)
Address City State ZIP
Printed Contact Name: Claim Payment Date:
VEHICLE INFORMATION
Vehicle Identification Number Year Model Make Body Style Model Color
License Plate Number
Previous Title Number Previous Title State
Check applicable box:
License plates and registration insignia for this motor vehicle are being surrendered, in accordance with Transportation Code
§501.0275. The registration for this vehicle is not currently suspended or revoked.
This vehicle has no license plates and/or registration.
INSURANCE COMPANY STATEMENT
I certify that I am an authorized representative of the above named insurance company; that a loss claim was paid and accepted for this
vehicle that does not meet the definition of salvage or nonrepairable; and, that two separate written notices were sent to the owner of
record requesting surrender or proper assignment of the original vehicle title. The statements on this application for the above described
vehicle are true and correct, to the best of my knowledge.
Printed Name of Applicant ________________________ Signature ____________________________ Date ____________
WARNING: Transportation Code, §501.155, provides that falsifying information on title transfer documents is a third-degree
felony offense punishable by not more than ten (10) years in prison or not more than one (1) year in a community correctional
facility. In addition to imprisonment, a fine of up to $10,000 may also be imposed.
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VTR-331-A
(09/11)
Page 2 of 2
Instructions
This form may be used if all of the following apply:
Applicant is an insurance company that is licensed to do business in Texas;
Insurance company acquired ownership or possession through payment of a claim at least 30 days earlier;
Insurance company is unable to surrender an ownership document or unable to surrender a properly assigned
ownership document;
Application is for an original Texas Certificate of Title; and
Application is for Title Only (registration will not be issued).
Notification requirements
:
At least two written notices must be sent to the owner and lienholder (if applicable) of record;
Proof of notifications are not submitted with the application but must be retained as part of the insurance
company’s normal record keeping retention
Verification of ownership:
a) If registered in Texas – Vehicle Inquiry of Texas title and registration
b) If registered outside of Texas – Verification of title and registration from the state of record. If not available, the
following is acceptable in lieu of out-of-state verification:
1) Insurance company sends a request for title and registration verification to the state of record and is
informed by letter that due to the Driver’s Privacy Protection Act restrictions, the state will forward the
lienholder’s notification to the owner(s); or
2) Does not receive a response from the governmental entity with which the motor vehicle is registered
on or before the 21
st
day after the date a request was submitted.
Application for Title:
Form VTR-331, Insurance Company Statement of Fact
Form 130-U, Application for Texas Certificate of Title
Proof of paid claim
Ownership evidence or verification of ownership
Title application fee of $28 or $33
Out-of-State Vehicles – The following documentation is also required:
1) Form VTR-221, Statement of Fact for Evidence of Ownership;
2) Out-of-State Identification Certificate (form VI-30); and
3) Weight Certificate on a commercial vehicle.
