Transcription of LABOR STATEMENT FOR REBUILT OR TOTAL LOSS VEHICLE
1 KENTUCKY TRANSPORTATION CABINET Department of VEHICLE Regulation DIVISION OF MOTOR VEHICLE LICENSING TC 96 353 Rev. 03/2022 Page 1 of 1 LABOR STATEMENT FOR REBUILT OR TOTAL LOSS VEHICLE INSTRUCTIONS: In accordance with the requirements outlined in KRS , KRS , and 601 KAR 9:200 Section 4, provide a descriptive list of repairs made and parts replaced. An original receipt for each part purchased must be submitted with this form. IF PARTS WERE PURCHASED FROM AN INDIVIDUAL (not a business), please provide on a separate sheet of paper, the following information: Name, complete address, and phone number of seller Parts acquired/purchased and note the VEHICLE identification number (VIN) of the VEHICLE from which those parts were taken (Note: If the seller cannot provide a VIN, then provide a notarized STATEMENT of why the VIN cannot be provided.)
2 SECTION 1: VEHICLE INFORMATION VEHICLE IDENTIFICATION # (VIN) MAKE MODEL BODY STYLE YEAR SECTION 2: REPAIRS & REPLACEMENT PARTS (Provide full description of repairs and list all parts replaced.) No. REPAIRS MADE PARTS REPLACED 1. None 2. None 3. None 4. None 5. None 6. None SECTION 3: ATTESTATION (Print legibly to avoid delay or denial of form processing.) I attest that myself or an employee (or owner) of First Name, Middle Initial, Last Name Full Business Name of Repair Shop did the repair work described in Section 2 on the VEHICLE named in Section 1 above. Signature Date Subscribed and attested before me on this day of , 20.
3 My commission number is and expires on . Notary Printed Name & Title Signature Penalties KRS : Any person who knowingly gives false, fraudulent, or erroneous information in connection with an application for the registration, and when required, titling of a VEHICLE , or any application for assignment of a VEHICLE identification number, or replacement documents, or gives information in connection with his review of applications, or falsely certifies the truthfulness and accuracy of information supplied in connection with the registration and when required, titling of a VEHICLE , shall be guilty of forgery in the second degree.
