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2. State of South Carolina
4. County of*
6. Name of owner(s) *
8. Address*
10. Make*
11. Model*
12. Year*
13. Body Style*
15. Vin Number*
16. Tag Number*
18. Personally appeared before me, stating that the identified owner of the vehicle described above has relinquished ownership for one of the following reasons:*

    1. Repossessed

    1. Accidental Loss
20. Leinholder/Insurance Co *
22. Address*
24. Date of Loss/Incident*
26. Disposition of Vehicle*
28. Signature*
30. Lienholder/Insurance Representative*
32. This form to be completed in it's entirity by the company verifying the loss of a vehicle.
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field