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Office of the Secretary of State AFFIRMATION SUPPORTING SALVAGE CERTIFICATE This form must accompany ... - page 1 / 2

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Office of the Secretary of State AFFIRMATION SUPPORTING SALVAGE CERTIFICATE This form must accompany all Salvage Certificates for which a Certificate of Title is requested

State of Illinois County of ______________________________

Rebuilder's Name

Rebuilder's #

Yr.

Contracted Rebuilder's Name

Rebuilder's #

Yr.

The undersigned hereby affirms to be the owner(s) of the below described vehicle, acquired by Salvage Certificate

No. from

____________________________

_______________________________________________________________________________________________

Yr.

Make

VIN

______________

______________________________________

___________________________________________________________________

Complete Section A or B: A. Rebuilder states that of parts listed on the reverse side of this affirmation, only the following have been

changed: Type of Part

VIN

Year

Make

Acquired From

________________ _________________________ ____ __________ _________________________ ________________ _________________________ ____ __________ _________________________ ________________ _________________________ ____ __________ _________________________ ________________ _________________________ ____ __________ _________________________ ________________ _________________________ ____ __________ _________________________ ________________ _________________________ ____ __________ _________________________ ________________ _________________________ ____ __________ _________________________ ________________ _________________________ ____ __________ _________________________

Rebuilder personally rebuilt the vehicle, or personally supervised its rebuilding. Rebuilder personally inspected the completed vehicle, and it complies with all safety requirements set forth in the Illinois Compiled Statutes, Chapter 625, and any regulations promulgated thereunder by the Secretary of State.

B. Rebuilder affirms that no essential parts have been removed, replaced, or damaged by flood, and that completion of this affirmation provides that this vehicle need not complete a successful salvage inspection as prescribed under Section 5/3-308 of the Illinois Compiled Statutes. Rebuilder further affirms that the vehicle was personally inspected, and it complies with all safety requirements set forth in the Illinois Compiled Statutes, Chapter 625, and any regulations promulgated thereunder by the Secretary of State.

I affirm, under penalty of perjury, that all information contained in this affirmation and its attachments is true and correct to the best of my knowledge.

______________________________________________________

(Signature of Rebuilder or Authorized Agent)

______________________________________________________

Date

______________________________________________________

(Signature of Contracted Licensed Rebuilder)

______________________________________________________

Date

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