that date, complete the declaration below and return it to the following address: PVB Correspondence - P.O. Box 30420 - Los Angeles, CA 90030.
Please do not leave any blank spaces on the form. Doing so may delay processing of your claim. In addition, one of the following required documentation must be
submitted along with the form below, as may be applicable to your claim. Please check one of the following:
Sold to someone else - Please submit ONE of the following:A copy of the Notice of Transfer and Release of Liability form that was filed with the DMV at the time of sale/transfer of the vehicle; OR
Bill of Sale/Trade-in agreement from a licensed car dealer or leasing company (Proof of private party sales are NOT accepted); OR
A copy of an IRS approved vehicle donation document from a charity. Leased/rented under a written agreement - Please submit the following:A copy of rental or lease agreement - Proof of written lease or rental agreement which includes the name, address, and driver’s license number of the person to
whom the vehicle is leased or rented must be submitted within 30 days of the “Notice Date”. Name and address of Responsible Party: (PLEASE PRINT LEGIBLY)City/State/Zip Code _______________________________________________________________________________________________________________________________
Date of sale, purchase, or lease/rental was executed (MM/DD/YYYY) ___ ___ / ___ ___ / ___ ___ ___ ___
License Plate Number ___________________________________________ FULL 16-DIGIT VIN: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ I declare under penalty of perjury that the foregoing is true and correct. _____________________________________________________________ ____________________________________*NOTE: If all information for the declaration of non-ownership is not accurately completed and verified by the DMV, the declaration will be disregarded and you will be