Title Inspection Form Title Inspection Form Submittal Number STATE OF NEBRASKA MOTOR VEHICLE IDENTIFICATION STATEMENT County * Madison Date Submitted * APPLICANT Name of Franchisee * Franchisee Address * Franchisee City * Franchisee State * Franchisee Zip * I affirm that all information on this form is true and correct. * Yes Name of person submitting this title inspection request * Your typed name serves as your signature on this form. Email address of person submitting this title inspection request Email REQUIRED to receive confirmation messages. Phone number of person submitting this title inspection request * VEHICLE DESCRIPTION Year * Make * Model * Color * VIN * If the VIN does not conform to the modern 17 character scheme, it must be inspected in person. Note: The letters I, O and Q never appear in a modern VIN. Odometer * Current Title No. * State * Previous Owner * Address * City * State * Zip * REQUIRED PHOTOS Photos must be submitted as requested. Incorrect photos will cause form to be rejected. NO PDF uploads. JPG files only. Front and driver's side of the vehicle * Drop a file here or click to upload Choose File Maximum file size: 10MB Rear and passenger side of the vehicle * Drop a file here or click to upload Choose File Maximum file size: 10MB VIN Plate * Drop a file here or click to upload Choose File Maximum file size: 10MB Federal door/frame sticker * Drop a file here or click to upload Choose File Maximum file size: 10MB Odometer reading * Drop a file here or click to upload Choose File Maximum file size: 10MB Front of the title * Drop a file here or click to upload Choose File Maximum file size: 10MB Back of the title * Drop a file here or click to upload Choose File Maximum file size: 10MB FRANCHISEE REQUIREMENTS The vehicle described above is currently located on the Franchisee's lot * Yes Current physical location of the vehicle - ADDRESS * City * State * Zip * Franchisee agrees to the vehicle described above will remain on the lot until notified by the Sheriff's Office that the inspection is complete. * Yes Franchisee agrees to maintain all submitted information for at least 5 years. * Yes Franchisee will allow Sheriff's Office personnel upon the dealership property to inspect submitted vehicle if deemed necessary by the Title Inspector * Yes Franchisee agrees to pay a $10 inspection fee for a total of $10 for each submitted vehicle. * Yes VEHICLE IDENTIFICATION INPSECTION Submit Δ
