Eastern Montana Motor Vehicle
Disposal Program
207 West Bell, Glendive,
MT 59330
Phone (406) 377-5772 Fax (406) 377-2022 dsnow@midrivers.com
www.dawsoncountymontana.org
Year Make
Model Color
V.I.N. License Plate #
Year
Title
# State
This
vehicle has (circle the appropriate answers):
Motor Frame Differential Transmission Body
Complete
Component
Parts (describe)
***All
non-automotive parts or materials must be removed before vehicle can be hauled.
***Only
5 tires (with wheels) per vehicle will be accepted.
CFC’S
(Freon) Y
/ N
This
vehicle is located at: (Give address or directions. Use back if necessary)
READ THIS BEFORE SIGNING
The undersigned, being the legal owner of, or having a legal interest in the vehicle described above, hereby authorizes a duly appointed agent of the County Junk Vehicle Program to remove this vehicle to an approved county motor vehicle graveyard. In the consideration of the foregoing removal, I hereby release all rights, title, and interest in the vehicle to the State of Montana and its agents without payment or compensation. To the best of my knowledge there is no lien against this vehicle, and I do not posses a certificate of title or Sheriff’s certificate of sale for this vehicle.
I agree to hold the State of Montana, the County,
and its agents harmless from any claims that my result from the foregoing
release and removal of this vehicle. I
understand that upon release of this vehicle to the towing operator of the Junk
Vehicle Program, there is no towing charge to me.
(Please
Print)
Name
of Responsible Party Phone
Address
Date Signed
Witness
(optional but recommended)
------------------------------------------------------------------------------------------------------------------------Office
Use Only-------------------------------------------------------------------------------------------------------------------
Date
Hauler Notified
Name
of Hauler Miles
Date
of pick up and delivery Vehicle #