Claim Submission Form

Complete all required fields and upload supporting documentation.

Requesting Party

The customer or business submitting this lien sale request

Business / Company Name*

Contact Name*

Business Address

NV DMV Business License #

FEIN

Contact Number*

Select all charges that apply and enter the total amount

Towing

Storage

Accessories or Supplies

Repair

Total $ Amount

Fees Already Paid

Amount Paid

Receipt Number

Date of Service

Balance Due (Storage + Accessories + Repair − Paid)

Add one or more vehicles included in this claim

Vehicle 1

VIN*

0/17

Year*

Make*

Model*

Body Type

Cylinders

Odometer

Color

Title Type

Standard TitleSalvage Title

Enter information for the primary registered owner and optionally a second owner

Registered Owner

First Name

Middle Name

Last Name

Physical Address

Upload any relevant files (PDF, JPG, PNG, DOC). Files will be organized by vehicle.

Drop a file here or browse

PDF, JPG, PNG, or DOC

By submitting this form you certify that all information is accurate and complete.