Form MVR-4F "Affidavit and Notification to Owner" - North Carolina

What Is Form MVR-4F?

This is a legal form that was released by the North Carolina Department of Transportation - Division of Motor Vehicles - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the North Carolina Department of Transportation - Division of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MVR-4F by clicking the link below or browse more documents and templates provided by the North Carolina Department of Transportation - Division of Motor Vehicles.

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Download Form MVR-4F "Affidavit and Notification to Owner" - North Carolina

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North Carolina Department of Transportation DIVISION OF 
Front MVR‐4F 
MOTOR VEHICLES
 (Rev.7/20)
AFFIDAVIT AND NOTIFICATION TO OWNER
$21.50 FEE
VEHICLE SECTION
TITLE NUMBER
YEAR
MAKE
VEHICLE IDENTIFICATION NUMBER
BODY STYLE
OWNER/REGISTRANT SECTION
Owner 1 ID # ___________________   ______________________________________________________________________________________________
Full Legal Name of Owner/Registrant 1 (First, Middle, Last, Suffix) or Company Name
Owner 2 ID # ___________________   ______________________________________________________________________________________________
Full Legal Name of Owner/Registrant 2 (First, Middle, Last, Suffix) or Company Name
Residence Address (Individual) Business Address (Firm)
City and State
Zip Code
County 
Mail Address (if different from above)
SECTION A:   CERTIFICATION BY INSURANCE COMPANY   
(COMPLETE IF TOTAL LOSS CLAIM  WAS  PAID)
This is to certify that the insurance company listed below has paid a total loss claim on the above listed vehicle. I also certify that a notice requesting 
the title was sent via certified mail to the owner and any recorded lienholder at least 30 days prior to submitting this form to the Division. Proof of 
payment of a total loss claim to the lienholder (if applicable)/owner is attached showing evidence that funds were paid to the first recorded 
lienholder shown in the Division's records. I certify that all information and supporting documents submitted are true and accurate.  
Proof of payment of total loss claim and proof of request for title sent to the Owner/Lienholder MUST  be attached to this form.
Name of Insurance Company 
Name of Claims Representative
Claim number
Phone # of Claims Representative
Address
City
State and Zip Code
SECTION B:    CERTIFICATION BY DEALER    
 (COMPLETE IF TOTAL LOSS CLAIM  WAS NOT  PAID)
This is to certify that I am a North Carolina used motor vehicle dealer whose primary business is the sale of salvage vehicles on behalf of insurance 
companies. I also certify that upon receiving a release statement from the insurer, a notice requesting the owner and any recorded lienholder to pick 
up the vehicle was sent via certified mail at least 30 days prior to submitting this form to the Division. I have attached the release from the insurer, 
copy of the notice and proof of delivery. I certify that all information and supporting documents submitted are true and accurate. 
Proof of  notice sent to the Owner and/or any Lienholder MUST be attached to this form.
Name of Dealer
Name of Agent for Dealer
Address
City
State and Zip Code
Notice Sent To:(Owner Name and Address)
Date Notice Mailed:
Notice Sent To:(Lienholder Name and Address)
     Odometer
To my knowledge the vehicle described herein:
Yes            No           Has been involved in a collision or other occurrence to the extent that the cost to
repair exceeds 25% of fair market retail price.
 _________________
Yes            No           Has been a flood vehicle, a reconstructed vehicle or a salvage vehicle.     
ONC  
      (odometer not certified)
Disclaimer : G.S. 20‐109‐1 (b) (2) "The Division shall not be subject to a claim under Article 31 of Chapter 143 of the General Statutes related to the cancellation of a title 
pursuant to this section if the claim is based on reliance by the Division on any proof of payment or proof of notice submitted to the Division by a third party pursuant to 
subdivision (b) (2) or subsection (e1) of this section.
Signature of Authorized Agent or Representative __________________________________________________________________________________
Date _______________________________ County __________________________________________ State _____________________________________
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she voluntarily signed the 
foregoing document for the purpose stated therein and in the capacity indicated: _________________________________ (Name(s) of Principal(s)).  
Notary Signature _____________________________________________   Notary Printed Name ______________________________________________
(SEAL)
My Commission Expires ____________________________________________
North Carolina Department of Transportation DIVISION OF 
Front MVR‐4F 
MOTOR VEHICLES
 (Rev.7/20)
AFFIDAVIT AND NOTIFICATION TO OWNER
$21.50 FEE
VEHICLE SECTION
TITLE NUMBER
YEAR
MAKE
VEHICLE IDENTIFICATION NUMBER
BODY STYLE
OWNER/REGISTRANT SECTION
Owner 1 ID # ___________________   ______________________________________________________________________________________________
Full Legal Name of Owner/Registrant 1 (First, Middle, Last, Suffix) or Company Name
Owner 2 ID # ___________________   ______________________________________________________________________________________________
Full Legal Name of Owner/Registrant 2 (First, Middle, Last, Suffix) or Company Name
Residence Address (Individual) Business Address (Firm)
City and State
Zip Code
County 
Mail Address (if different from above)
SECTION A:   CERTIFICATION BY INSURANCE COMPANY   
(COMPLETE IF TOTAL LOSS CLAIM  WAS  PAID)
This is to certify that the insurance company listed below has paid a total loss claim on the above listed vehicle. I also certify that a notice requesting 
the title was sent via certified mail to the owner and any recorded lienholder at least 30 days prior to submitting this form to the Division. Proof of 
payment of a total loss claim to the lienholder (if applicable)/owner is attached showing evidence that funds were paid to the first recorded 
lienholder shown in the Division's records. I certify that all information and supporting documents submitted are true and accurate.  
Proof of payment of total loss claim and proof of request for title sent to the Owner/Lienholder MUST  be attached to this form.
Name of Insurance Company 
Name of Claims Representative
Claim number
Phone # of Claims Representative
Address
City
State and Zip Code
SECTION B:    CERTIFICATION BY DEALER    
 (COMPLETE IF TOTAL LOSS CLAIM  WAS NOT  PAID)
This is to certify that I am a North Carolina used motor vehicle dealer whose primary business is the sale of salvage vehicles on behalf of insurance 
companies. I also certify that upon receiving a release statement from the insurer, a notice requesting the owner and any recorded lienholder to pick 
up the vehicle was sent via certified mail at least 30 days prior to submitting this form to the Division. I have attached the release from the insurer, 
copy of the notice and proof of delivery. I certify that all information and supporting documents submitted are true and accurate. 
Proof of  notice sent to the Owner and/or any Lienholder MUST be attached to this form.
Name of Dealer
Name of Agent for Dealer
Address
City
State and Zip Code
Notice Sent To:(Owner Name and Address)
Date Notice Mailed:
Notice Sent To:(Lienholder Name and Address)
     Odometer
To my knowledge the vehicle described herein:
Yes            No           Has been involved in a collision or other occurrence to the extent that the cost to
repair exceeds 25% of fair market retail price.
 _________________
Yes            No           Has been a flood vehicle, a reconstructed vehicle or a salvage vehicle.     
ONC  
      (odometer not certified)
Disclaimer : G.S. 20‐109‐1 (b) (2) "The Division shall not be subject to a claim under Article 31 of Chapter 143 of the General Statutes related to the cancellation of a title 
pursuant to this section if the claim is based on reliance by the Division on any proof of payment or proof of notice submitted to the Division by a third party pursuant to 
subdivision (b) (2) or subsection (e1) of this section.
Signature of Authorized Agent or Representative __________________________________________________________________________________
Date _______________________________ County __________________________________________ State _____________________________________
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she voluntarily signed the 
foregoing document for the purpose stated therein and in the capacity indicated: _________________________________ (Name(s) of Principal(s)).  
Notary Signature _____________________________________________   Notary Printed Name ______________________________________________
(SEAL)
My Commission Expires ____________________________________________
Back MVR-4F
(Rev.11/13)
PURPOSE
This form is to be used by an NC insurance company when a salvage vehicle owner fails to assign and deliver the vehicle's certificate of
title to the insurer within 30 days of the payment of the claim in accordance with North Carolina General Statute 20-109(b)(1). This
form may also be used by a North Carolina car dealer, whose primary business whose is the sale of salvage vehicles on behalf of insurers
and taking possession of salvage vehicles that are the subject of insurance claims, where an owner or lienholder abandons the vehicle.
INSTRUCTIONS FOR THE INSURANCE COMPANY
Insurer must send certified request for title at least 30 days prior to submitting request from the Division and provide proof of delivery.
Insurer must provide proof of payment of the claim. Insurer must provide evidence that funds were paid to the first lienholder shown on
the Division's record. Insurer must complete all application sections of the form including odometer and damage disclosure certification.
Upon receipt of form MVR-4F, supporting documents and a fee of $15.00 the Division will issue the insurer an MVR-40 (salvage
certificate) to be used to sell the vehicle.
INSTRUCTIONS FOR THE NC DEALER
Dealer must be licensed in North Carolina and operate a business in accordance with North Carolina General Statutes 20-109(e1). Dealer
must have authorization from the insurance company to release the vehicle to the owner or lienholder. Dealer must have possession of
vehicle for 30 days. Dealer must send notification via certified mail to the lienholder or owner informing them that the vehicle is
available for pickup. Notice shall include outstanding charges owed to the motor vehicle dealer. Dealer must provide proof of delivery of
notice. Dealer may submit request for title by submitting MVR-4F if the vehicle is not picked up within 30 days. Dealer must complete all
applicable sections of the form including odometer and damage disclosure certification. Upon receipt of form MVR-4F, supporting
documents and a fee of $15.00, the Division will issue the Dealer a MVR-40 (salvage certificate) to be used to sell the vehicle.
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