Removal and/or Inspection of a Motor Vehicle at a VSF

This Form is Approved by the Texas Department of Licensing and Regulation

Section ONE

Check one of the following boxes:

Box 1 : I am an immediate family member (parent, spouse, brother, sister, or child) of the owner of thevehicle. When selected, this form may be used as the Affidavit of Right of Possession Form.Box 2: I am an authorized representative of the owner of the vehicle.Box 3: I am an authorized representative of an insurance company authorized to conduct business in the State of Texas

Section TWO

Check one of the following boxes:

I will remove the vehicleI will inspect the vehicle

Section three

Describe the motor vehicle and person authorized to inspect or remove the vehicle:

Vehicle Year, Make and Model:


VIN or License Plate Number:


Describe the person removing or inspecting the motor vehicle:

First and Last Name:

Company Name (if a representative of a company):

If a tow truck is used to remove the vehicle, complete the following:

Tow Operator TDLR Lic. No:

Tow Truck TDLR No


Section four

Complete this section ONLY IF you checked Box 1 or Box 2 in SECTION ONE above:

On this date appeared who upon oath declared that:

The authority granted herein is limited to either (i) inspecting the vehicle or (ii) making payment to and removing the described
vehicle from (name of the Vehicle Storage Facility).

This Authority to Act shall expire the earlier of three (3) days from its date of execution, or at an earlier date if revoked by me in writing, or when the motor vehicle is returned to my possession.

Signed this

Signature:

Subscribed and sworn to before me on this

Notary Signature:

Notary Public, State of

My commission expires:

Section five

Complete this section ONLY IF you checked Box 3 in SECTION ONE above:

I am a duly authorized licensed Insurance Adjuster I work for or represent (Name of Insurance Company) authorized to conduct business in the State of Texas. My Texas Department of Insurance Adjuster License # is: . The claim related to this vehicle settled or, prior to settlement, the vehicle owner expressly authorized its inspection and/or removal.

Signature:

Date:

Printed Name:

Insurance Claim#:

I understand, acknowledge, and agree that by typing my name on this document, my typed name is an electronic signature and this document has the same legally binding consequence as if executed with a traditional signature.

INSTRUCTIONS

When completed according to these instructions and presented by a person named in the form with conforming identification, a VSF may not delay release or inspection of the vehicle. VSF’S must accept facsimiles or copies of this document

FAMILY MEMBERS

An immediate family member of the owner of the vehicle may remove or inspect the vehicle using this form and:

  1. Checking Box 1 in Section One
  2. Checking the appropriate box in Section Two
  3. Completing Section Three
  4. Completing Section Four in the presence of a notary
  5. Leaving Section Five blank

OTHER PERSONS WITH POWER OF ATTORNEY

Any other person authorized by the owner of the vehicle may remove or inspect the vehicle using this form and:

  1. checking Box 2 in Section One
  2. Checking the appropriate box in Section Two
  3. Completing Section Three
  4. having the owner of the vehicle complete Section Four in the presence of a notary
  5. Leaving Section Five blank

INSURANCE COMPANY REPRESENTATIVES

An insurance company’s authorized representative may remove or inspect the vehicle using this form and:

  1. Checking Box 3 in Section One
  2. Checking the appropriate box in Section Two
  3. Completing Section Three (Note: This section identifies the person inspecting or removing the vehicle; may be different from the person named in Section 5)
  4. Leaving Section Four blank
  5. Completing Section Five. (Note: This section provides the authorization to inspect or remove the vehicle; may be different from the person named in Section 3)