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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
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Maine
Maryland
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Pennsylvania
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Tennessee
Texas
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Vermont
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Washington
West Virginia
Wisconsin
Wyoming
Zip:
Vehicle Information
Vehicle Identification No.:
Year:
Make:
Model
Doors
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2 Door
4 Door
Hatchback
Trim Level (if known)
Exterior Color:
Transmission
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Automatic
Manual
Cylinders
Liters
Mileage:
Drive Train
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4WD
AWD
FWD
RWD
Lien Holder
Estimated Payoff
Vehicle Options
A/C
choose one:
Yes
No
Alloy Wheels
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Yes
No
ABS
choose one:
Yes
No
AM/FM Radio
choose one:
Yes
No
CD
choose one:
Yes
No
CD Changer
choose one:
No
In Dash
External
Cruise Control
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Yes
No
Dual Air Bags
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Yes
No
DVD or Entertainment System
choose one:
Yes
No
Leather Seating
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Yes
No
Navigation System
choose one:
Yes
No
Power Locks
choose one:
Yes
No
Power Windows
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Yes
No
Power Seat(s)
choose one:
No
Driver
Pass
Both
Roof Rack
choose one:
Yes
No
Side Air Bags
choose one:
Yes
No
Sunroof
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No
Sliding
Pop-up
Tow Package
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Yes
No
Overall Vehicle Condition
Rate the condition of the following: 1 being Poor, 10 being Excellent.
Metal/Paint (Scratches, dings, dents, rust, fading)
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1
2
3
4
5
6
7
8
9
10
Tires (50% tread wear - replacement)
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1
2
3
4
5
6
7
8
9
10
Upholstery (Tears, burns, stains)
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1
2
3
4
5
6
7
8
9
10
Glass (Fractures, spiders, chips)
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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)
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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
Have any of the painted surfaces been repainted or touched up?
choose one:
yes
no
Are there any dents and dings?
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
Has the transmission or engine ever been replaced?
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
Questionnaire
Has the vehicle ever been a taxi, rental car, or police car?
choose one:
yes
no
Has the vehicle ever had a salvage title?
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yes
no
Has the vehicle ever been declared a total loss?
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 this a "lemon law buyback" 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
Is the pollution control equipment attached and working properly?
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 there anything else we should know about this vehicle?