Form H-116 "Vehicle Statement of Value Completed by a Licensed Dealer or Repairer" - Connecticut

What Is Form H-116?

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

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Connecticut Department 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 H-116 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form H-116 "Vehicle Statement of Value Completed by a Licensed Dealer or Repairer" - Connecticut

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VEHICLE STATEMENT OF VALUE COMPLETED
BY A LICENSED DEALER OR REPAIRER
H-116 REV. 3-2018
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
DEALERS AND REPAIRERS SECTION
On The Web At ct.gov/dmv
VEHICLE YEAR
VEHICLE MAKE
VEHICLE MODEL
VEHICLE IDENTIFICATION NUMBER
NAME OF THE DEALER/REPAIRER AND PHONE NUMBER
ADDRESS OF THE DEALER/REPAIRER
(Number and Street)
(City or Town)
(State)
(Zip Code)
As a Dealer or Repairer licensed by the State of Connecticut, it is in our professional opinion that the
vehicle described above is valued at less than one thousand five hundred dollars ($1,500) for one or more
of the following reasons:
Extensive body and/or frame damage.
Vehicle stripped/missing body parts.
Damaged by fire.
No key, no way to determine if vehicle is in running condition or mechanically fit for operation on the
highways of the State of Connecticut.
Extensive interior damage.
Steering column/ignition assembly damaged.
Extensive body or frame rot.
Tires missing.
Broken windshield and/or windows.
High mileage
.
Other (Explain)
PLEASE INCLUDE A PHOTOGRAPH OF THE VEHICLE DESCRIBED ABOVE.
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, the undersigned, under penalty of false statement,
in accordance with the provisions of Sections 14-110 and 53a-157b of the Connecticut General Statutes. I understand that if I make a statement
which I do not believe to be true with the intent to mislead the Commissioner, I will be subject to prosecution under the above-cited laws.
SIGNATURE OF LICENSEE
DEALER/REPAIRER LICENSE NUMBER
DATE SIGNED
X
VEHICLE STATEMENT OF VALUE COMPLETED
BY A LICENSED DEALER OR REPAIRER
H-116 REV. 3-2018
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
DEALERS AND REPAIRERS SECTION
On The Web At ct.gov/dmv
VEHICLE YEAR
VEHICLE MAKE
VEHICLE MODEL
VEHICLE IDENTIFICATION NUMBER
NAME OF THE DEALER/REPAIRER AND PHONE NUMBER
ADDRESS OF THE DEALER/REPAIRER
(Number and Street)
(City or Town)
(State)
(Zip Code)
As a Dealer or Repairer licensed by the State of Connecticut, it is in our professional opinion that the
vehicle described above is valued at less than one thousand five hundred dollars ($1,500) for one or more
of the following reasons:
Extensive body and/or frame damage.
Vehicle stripped/missing body parts.
Damaged by fire.
No key, no way to determine if vehicle is in running condition or mechanically fit for operation on the
highways of the State of Connecticut.
Extensive interior damage.
Steering column/ignition assembly damaged.
Extensive body or frame rot.
Tires missing.
Broken windshield and/or windows.
High mileage
.
Other (Explain)
PLEASE INCLUDE A PHOTOGRAPH OF THE VEHICLE DESCRIBED ABOVE.
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, the undersigned, under penalty of false statement,
in accordance with the provisions of Sections 14-110 and 53a-157b of the Connecticut General Statutes. I understand that if I make a statement
which I do not believe to be true with the intent to mislead the Commissioner, I will be subject to prosecution under the above-cited laws.
SIGNATURE OF LICENSEE
DEALER/REPAIRER LICENSE NUMBER
DATE SIGNED
X