ClaimForm

Claim Form

Claimant Information

First Name
Last Name

Please provide your current mailing address.

Please check if a non-U.S. address
Mailing Address
Continuation of Mailing Address
City

State
Zip Zip4

Province
Postal Code
Country

Daytime Phone
Evening Phone Please Leave Empty
Email Address

Vehicle Information

Make
Model
License Plate Number
Vehicle Identification Number (VIN)

Dealer Who Is The Subject Of Your Claim

Dealer's Trade Name
Dealer's Address
City
State
Zip Code Zip4
Telephone Number
To your knowledge, is the dealer still in business? Yes No
Explain

Claim Information

Dealer Failed To

You Must Provide

Transfer License or Registration Fees to DMV

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• A copy of your contract with the dealer

Pay the Proceeds of a Consignment Sale

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• A copy of consignment agreement
• Document(s) showing sale of consigned vehicle

Pay Off the Remaining Lien Amount on your Trade-In Vehicle

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• A billing statement, or other documents from your lender, showing the amount due
• A copy of your contract with the dealer

Provide Good Title

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• A copy of your contract with the dealer
• A billing statement, or other documents from the legal owner or other claimant of amount claimed to be owed and the amount, if any, that he or she received from the dealer or lessor-retailer

Pay Third Parties for Insurance, Service Contract, or Goods or Services

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• A copy of your contract with the dealer
• A billing statement, or other documents from the third party of the amount, if any, that he or she received from the dealer or lessor-retailer

Amount Claimed
Date Of Incident
Describe the events on which you base this claim:

Have you taken any action to recover all or part of the claim, such as making a claim under the dealer's bond or suing in Small Claims Court? Yes No

Amount Claimed
Please explain the result and current status:

Have any payments been made toward the balance owed on your trade-in since the contract was signed?
Yes No

Payor 1

Date Paid

Amount Paid

Payor 2

Date Paid

Amount Paid

Payor 3

Date Paid

Amount Paid

Payor 4

Date Paid

Amount Paid

Payor 5

Date Paid

Amount Paid

Payor 6

Date Paid

Amount Paid

Required Documentation

Please include the requested documents related to the type of claim you are filing. Be advised that the CMVRC may require reasonable additional information to process eligible claims.

YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO TRANSFER LICENSE OR REGISTRATION FEES, PLEASE PROVIDE:
- A copy of your agreement or contract with the Dealer/Lessor-Retailer
YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO PAY THE PROCEEDS OF A CONSIGNMENT SALE, PLEASE PROVIDE:
- A copy of the consignment agreement
- All documents showing sale of consigned vehicle
IF YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO PAY THE BALANCE OWING ON YOUR TRADE-IN VEHICLE, PLEASE PROVIDE:
- A billing statement, or other document from your lender, showing the amount due
- A copy of your agreement or contract with the Dealer/Lessor-Retailer
IF YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO PROVIDE GOOD TITLE, PLEASE PROVIDE:
- A copy of your contract with the Dealer-Lessee-Retailer
- A billing statement, or other documents from the legal owner, such as a bank or finance company, or other claimant of the amount that is claimed to be owed and the amount, if any, that he or she received from the dealer or lessor-retailer.
IF YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO PAY THIRD PARTIES FOR INSURANCE, SERVICE CONTRACTS, OR GOODS OR SERVICES PURCHASED THROUGH THE DEALER, PLEASE PROVIDE:
- A copy of your agreement or contract with the Dealer-Lessor-Retailer
- A billing statement, or other documents from the third party of the amount, if any, that he or she received from the dealer or lessor-retailer

Upload Your Documentation

Uploaded Files

Your Obligation To Update Information And Authorization For CMVRC To Obtain Information

You must notify the CMVRC of any changes or updates to the information contained in your claim form, including notice of any payments you have received from your insurance company, the dealer, the dealer’s bond, or any other person or entity. If you fail to notify the CMVRC of any changes or updates, the CMVRC may deny your claim. You agree to repay to the CMVRC to the extent you receive any money from anyone for the loss covered by CMVRC’s payment to you.

The CMVRC may contact the Dealer/Lessor-Retailer, the Department of Motor Vehicles, a financial institution or others to get information about your claim.

By signing this Claim Form, you authorize the CMVRC to request and obtain information to determine whether your claim is eligible for payment. You authorize the Dealer/Lessor-Retailer that is the subject of this claim, the Department of Motor Vehicles, lessors, financial institutions, and other persons to cooperate with the CMVRC and to release to the CMVRC any record(s) or other information that the CMVRC in its discretion may request to determine whether your claim is eligible for payment.

5. Certification I declare under penalty of perjury under the laws of the State of California that the information provided in this claim and accompanying documents is true and correct.

Required