Form PS2123-04 "Motor Vehicle Dealer Close out Statement" - Minnesota

What Is Form PS2123-04?

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

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Minnesota Department of Public Safety;
  • 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 PS2123-04 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS2123-04 "Motor Vehicle Dealer Close out Statement" - Minnesota

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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
445 Minnesota Street, Suite 186
Saint Paul, MN 55101-5186
Phone: (651) 201-7800 Fax: (651) 297-1480 TTY: (651) 282-6555
Web: dvs.dps.mn.gov Email: DVS.DealerQuestion@state.mn.us
Mot o r V eh ic le De al er C lo se O ut S ta tem en t
I,
, as
of
(Full Name)
(Title)
,certify that the aforementioned dealership has discontinued business as
(Dealership)
a Minnesota Motor Vehicle Dealer under dealer license number
effective
(Dealer Number)
.
(Date)
I further certify that all vehicles, which were in inventory under this license, have been disposed of.
Vehicles have been (please check all that apply):
Sold at retail
Sold at wholesale
Title and registered to the owners and officers of said dealership with proper amount of excise tax having been paid.
(Lessors only) Existing leases are being allowed to run out with no new leases being initiated. We will be fully bonded
during this period. Vehicles not purchased by the lessee will be titled and registered to the owners and officers of said
dealership with proper amount of excise tax having been paid.
I further certify that I have surrendered:
Dealer Plate Number(s):
(Plate Numbers)
Supplemental Dealer Reassignment Number(s):
21-Day Permit Books:
(Permit Numbers)
31-Day Permit Books:
(Permit Numbers)
Dealer License Certificate assigned under this license to:
Minnesota Dealers Unit on
by (choose one):
(Date)
Dealer Examiner
on
(Name)
(Date)
I am unable to locate plate number(s):
and/or permit number(s):
,which will be surrendered immediately to the
Department of Public Safety Dealer Unit should they be recovered.
has been designated as a contact person for follow-up inquiries, s/he
(Print Full Name)
may be contacted at:
.
(Phone)
X
Date
Signature and Title
PS2123-04 (05/15)
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
445 Minnesota Street, Suite 186
Saint Paul, MN 55101-5186
Phone: (651) 201-7800 Fax: (651) 297-1480 TTY: (651) 282-6555
Web: dvs.dps.mn.gov Email: DVS.DealerQuestion@state.mn.us
Mot o r V eh ic le De al er C lo se O ut S ta tem en t
I,
, as
of
(Full Name)
(Title)
,certify that the aforementioned dealership has discontinued business as
(Dealership)
a Minnesota Motor Vehicle Dealer under dealer license number
effective
(Dealer Number)
.
(Date)
I further certify that all vehicles, which were in inventory under this license, have been disposed of.
Vehicles have been (please check all that apply):
Sold at retail
Sold at wholesale
Title and registered to the owners and officers of said dealership with proper amount of excise tax having been paid.
(Lessors only) Existing leases are being allowed to run out with no new leases being initiated. We will be fully bonded
during this period. Vehicles not purchased by the lessee will be titled and registered to the owners and officers of said
dealership with proper amount of excise tax having been paid.
I further certify that I have surrendered:
Dealer Plate Number(s):
(Plate Numbers)
Supplemental Dealer Reassignment Number(s):
21-Day Permit Books:
(Permit Numbers)
31-Day Permit Books:
(Permit Numbers)
Dealer License Certificate assigned under this license to:
Minnesota Dealers Unit on
by (choose one):
(Date)
Dealer Examiner
on
(Name)
(Date)
I am unable to locate plate number(s):
and/or permit number(s):
,which will be surrendered immediately to the
Department of Public Safety Dealer Unit should they be recovered.
has been designated as a contact person for follow-up inquiries, s/he
(Print Full Name)
may be contacted at:
.
(Phone)
X
Date
Signature and Title
PS2123-04 (05/15)