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Contact Information
State Issued:
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Vehicle Information
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2 Door
4 Door
Hatchback
choose one:
Automatic
Manual
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4WD
AWD
FWD
RWD
Liters
Exterior Color
Interior Color
Vehicle Identification No.:
Lien Holder
Estimated Payoff
Vehicle Options
AM/FM Radio
choose one:
Yes
No
Cassette
choose one:
Yes
No
CD
choose one:
Yes
No
CD Changer
choose one:
No
In Dash
External
Power Windows
choose one:
Yes
No
Power Locks
choose one:
Yes
No
A/C
choose one:
Yes
No
Rear A/C
choose one:
Yes
No
ABS
choose one:
Yes
No
Cruise Control
choose one:
Yes
No
Tilt Control
choose one:
Yes
No
Roof Rack
choose one:
Yes
No
Sunroof
choose one:
No
Sliding
Pop-up
Alloy Wheels
choose one:
Yes
No
Tow Package
choose one:
Yes
No
Dual Air Bags
choose one:
Yes
No
Side Air Bags
choose one:
Yes
No
Power Seat(s)
choose one:
No
Driver
Pass
Both
Leather Seating
choose one:
Yes
No
DVD or Entertainment System
choose one:
Yes
No
Overall Vehicle Condition
Rate the condition of the following: 1 being Poor, 10 being Excellent.
Metal/Paint (Scratches, dings, dents, rust, fading)
choose one:
1
2
3
4
5
6
7
8
9
10
Tires (50% tread wear - replacement)
choose one:
1
2
3
4
5
6
7
8
9
10
Upholstery (Tears, burns, stains)
choose one:
1
2
3
4
5
6
7
8
9
10
Glass (Fractures, spiders, chips)
choose one:
1
2
3
4
5
6
7
8
9
10
Clutch (Clutch slipping)
choose one:
1
2
3
4
5
6
7
8
9
10
n/a
Brakes (Squeaky, noisy)
choose one:
1
2
3
4
5
6
7
8
9
10
Collision History
Has your vehicle ever been involved in a collision?
choose one:
yes
no
If yes, was a Body Shop estimate of repairs written?
choose one:
n/a
yes
no
Were Body Shop repairs performed?
choose one:
n/a
yes
no
Was the vehicle repaired to your complete satisfaction?
choose one:
n/a
yes
no
Exterior Condition
Are any of the painted surfaces scratched, rusted, or faded?
choose one:
yes
no
Are there any dents and dings?
choose one:
yes
no
Have any of the painted surfaces been repainted or touched up?
choose one:
yes
no
Does any of the glass have fractures, spiders, or chips?
choose one:
yes
no
Interior Condition
Does the upholstery have tears, burns, or stains?
choose one:
yes
no
Does the stereo system or any of its components need repairs?
choose one:
yes
no
Do all of the gauges and dash functions work?
choose one:
yes
no
Mechanical Condition
Does the engine need any repairs?
choose one:
yes
no
Does the transmission need any repairs?
choose one:
yes
no
Is the clutch slipping or need any repairs?
choose one:
n/a
yes
no
Are the brakes squeaking or in need of repair?
choose one:
yes
no
Has the transmission or engine ever been replaced?
choose one:
yes
no
Questionnaire
Has the vehicle ever been a taxi, rental car, or police car?
choose one:
yes
no
Has the vehicle ever been in water deeper than the midpoint of the tires?
choose one:
yes
no
Has the vehicle ever been declared a "Flood" vehicle?
choose one:
yes
no
Is the vehicle's frame in need of repair?
choose one:
yes
no
Has your vehicle's frame ever been repaired?
choose one:
yes
no
Has the vehicle ever had a salvage title?
choose one:
yes
no
Is this a "lemon law buyback" vehicle
choose one:
Yes
NO
Has the vehicle ever been declared a total loss?
choose one:
yes
no
Is the vehicle air bag in working order?
choose one:
yes
no
Has the vehicle air bag ever been deployed?
choose one:
yes
no
Do you have any of the service records for this vehicle?
choose one:
yes
no
Do you have records for any oil change within the last 5000 miles?
choose one:
yes
no
Is the catalytic converter attached and working properly?
choose one:
yes
no
Are the inspection stickers current?
choose one:
yes
no
Has the spare tire ever been used?
choose one:
yes
no
Do any of the tires need to be replaced?
choose one:
yes
no
Is the pollution control equipment attached and working properly?
choose one:
yes
no
Is there anything else we should know about this vehicle?
