For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

3VW2K7AJ6DM449783

71300 JACINTO DRIVE APT 108

Rancho Mirage CA 92270

3000246978-1-13000246978-1-1

04/09/2014

Rancho Mirage CA 92270

71300 JACINTO DRIVE APT 108

3VW2K7AJ6DM449783

VEHICLEA/ESSEL TRANSFER AND REASSIGNM ENT FORMA Public Service Agency

INSTRUCTIONS ON REVERSE SIDE - ALL SIGNATURES MUST BE IN INK _ PHOTOCOPIES NOT ACCEPTEDThisformlsnottheownershipcertifhaE.ItmustaccompanythetittingdocumentorApplication for DuplicateTitle. For Car Buyer's Bill ot Rights, visitwww.dmv.ea.gov. I

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MOTORCYCLE ENGINE NUMBER

sell, transfer, and deliver the above vehicle/vessel

$(SELLTNG PRrCE)

PRINT SELLER'S NAME(S)

for the amount ofPRINT BUYER'S NAME(S) DAY YEAR

(e.9., parents, spouse, friend, etc.)lf this was a gift, indicate relationship:

sEciioN s ! odoMErER 'p|sctosung siAtEUEryi ,(w. ia'i;t:uiieaee,is nit*oc #Federal and State Law requires that you state the mileage upon transfer of ownership. Failure to complete or providinga false stafement may result in fines andlor imprisonment.

WARNING_ODOMETER DISCREPANCYflOdometer reading is NOT theactual mileage n Viteage EXCEEDS the odomerer meghgnig,?! linilSExplain edometer discrepancy:

LICENSE PLAf,VCF NO:

SIGNATURE REOUIRED BY PERSON

XSIGNATURE REOUIRED BY PERSON APPOINTING POWER OF ATTORNEY

X

I.acknowledge tlg ?dory_eter reading aq! the facts of the transter.l certity (or dectare) under penatty ot perjury underthe laws of the Stafe of Calitornia that the toreqoinq is true and correct.

BUYER'S SECTION

DL/ID OB DEALEF/DISM #

DUID OR DEALER/DISM #

DUID OF DEALER/DISM +

DAYTIME TELEPHONE NO

SELLER'S SECTIONI certify (or declare) under penalty of perjury under the laws of the Stafe of California that the foregoing is true anctcorrect.

DUID OR DEALER/DISM #

DUID OR DEALER/DISM #

DAYTIME TELEPHONE NO,

l/We appointulzE

PF

Lotr|rl=

PRINT NAME(S)

as my attorney in fact, to complete all necessary documents, as needed,PRINT NAME(S)

BEG 262 (REV 10/2011)

to transfer ownership as required by law.

3VW2K7AJ6DM449783 2013 VOLKSWAGEN 7CMF419

DENNIS BELITZ

Farmers Insurance Exchange

DENNIS BELITZ

71300 JACINTO DRIVE APT 108 Rancho Mirage CA 92270 (760) 565-6874

DENNIS BELITZ Farmers Insurance Exchange

3000246978-1-13000246978-1-1

Farmers Insurance Exchange

Farmers Insurance Exchange

71300 JACINTO DRIVE APT 108 Rancho Mirage

DENNIS BELITZ

DENNIS BELITZ

(760) 565-6874CA 92270

04/09/2014

04/09/2014

7CMF419VOLKSWAGEN

DENNIS BELITZ

3VW2K7AJ6DM449783 2013

SIGNATURE OF INDIVIDUAL OR COMPANY’S AUTHORIZED EMPLOYEE DATE DAYTIME PHONE NUMBER

PRINT TRUE FULL NAME PRINT TRUE FULL NAME

ADDRESS CITY STATE ZIP CODE

PRINT TRUE FULL NAME

ADDRESS CITY STATE ZIP CODE

PRINTED NAME OF INDIVIDUAL/COMPANY WHO PAID FOR LOSS OF VEHICLE

ADDRESS CITY STATE ZIP CODE

APPLICATION FOR VEHICLE LICENSE FEE REFUND: Unrecovered Total Loss Vehicle—Complete Part A Constructive Total Loss OR Nonrepairable Vehicle—Complete Part

A Public Service Agency

LICENSE PLATE NUMBER VEHICLE ID NUMBER YEAR MODEL MAKE

B

I was the registered owner on the date the vehicle was wrecked, destroyed, or damaged. I was not cited or convicted of driving under the infl uence of alcohol or drugs (VC §23152, §23153, or §23103). I did not plea bargain a reduced sentence for driving under the infl uence in connection with the loss of this vehicle (VC §23103.5). I am aware that the requested refund will be issued to the person or company named in part 2 below.I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.SIGNATURE DATE DAYTIME PHONE NUMBER

SIGNATURE DATE DAYTIME PHONE NUMBERX ( )

1. Registered Owner(s) of Record completes this part (if jointly owned, all owners must sign):

I am now the owner of this vehicle. At least 60 days have passed since the vehicle was stolen and it has not been found. I am requesting a refund of the remaining current registration year’s license fees. I understand that the fees must be repaid to DMV if the vehicle is recovered in the same registration year for which fees are refunded. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

The license plates for this vehicle have been: SURRENDERED LOST STOLEN DESTROYED RETAINED BY OWNER FOR REASSIGNMENT MUTILATED

NOTE: AN ADMINISTRATIVE FEE WILL BE WITHHELD FROM THE REFUND.PART A—UNRECOVERED TOTAL LOSS VEHICLE — A COPY OF THE POLICE REPORT MUST BE ATTACHED IF A DEPARTMENT OF JUSTICE STOLEN VEHICLE UPDATE IS NOT INCLUDED IN THE VEHICLE REPORT TO THEDEPARTMENT.

SIGNATURE OF INDIVIDUAL OR COMPANY’S AUTHORIZED EMPLOYEE DATE DAYTIME PHONE NUMBER

X

I am now the owner of this vehicle. I am requesting a refund of the remaining current registration year’s license fees. I understand that the fees must be repaid to DMV if the vehicle is reregistered in the same registration year for which fees are refunded. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

PART B—CONSTRUCTIVE TOTAL LOSS OR NONREPAIRABLE VEHICLE

X ( )

2. Individual or Company who paid for loss of vehicle (owner of the salvage value of vehicle):

Vehicle was wrecked, destroyed, or damaged by a single event on this date:

WHERE TO MAIL THE REFUND REQUEST

X ( )

Department of Motor Vehicles, P.O. Box 942869, Sacramento, CA 94269-0001REG 65 (REV. 4/2007) WWW

( )

MO. DA. YR.

MO. DA. YR.Vehicle was stolen on this date: MO. DA. YR.Reported to police on this date:

Name and location of Police Agency ___________________________________________________________________Registered Owner(s) of RecordPRINT TRUE FULL NAME PRINT TRUE FULL NAME

ADDRESS CITY STATE ZIP CODE

7CMF419 3VW2K7AJ6DM449783 2013 NEW JETTA VOLKSWAGEN

October 28 2013

DENNIS BELITZ

Farmers Insurance Exchange 3000246978-1-13000246978-1-1Farmers Insurance Exchange

04/09/2014

28October 2013

7CMF419 VOLKSWAGENNEW JETTA

DENNIS BELITZ

3VW2K7AJ6DM449783 2013

DEFINITIONS: (California Code of Regulations Title 13)

Unrecovered Total Loss-A vehicle subject to registration which has been stolen and not recovered within 60 days from the police report date. The vehicle must be transferred to the individual or company who paid you for the loss of your vehicle (insurance company, etc.) §10902 R&T.

Constructive Total Loss-A vehicle which has been wrecked, destroyed, or damaged to such extent that the owner, or the insurance company, considers it uneconomical to repair the vehicle and because of this, the vehicle is not repaired by or for the person who owned the vehicle (VC §544). A Salvage Certifi cate must be issued for this vehicle before a refund request will be processed. §11515 VC, §10902 R&T.

Nonrepairable Vehicle-A vehicle that has no value except as a source of parts or scrap metal, or was found completely stripped after the theft, or has been completely burned. (VC §431). A Nonrepairable Certifi cate must be issued for this vehicle before a refund will be processed. §10902 R&T.

REG 65 (REV. 4/2007) WWW

7CMF419 3VW2K7AJ6DM449783 2013 VOLKSWAGEN7CMF419 VOLKSWAGEN3VW2K7AJ6DM449783 2013

04/09/2014

KNTU86JYAL4WPLV5E26EDD

DENNIS BELITZ

Party ID: 92M4XKINAIRP9KVUEULUGLIP Address: 66.74.212.135

VERIFIED EMAIL: dennis.belitz@gmail.com

Multi-FactorDigital Fingerprint Checksum d8a1f1353e9d0d4c9f4b0b6f245e6e0e3da7857b

Timestamp Audit2014-04-09 14:11:22 -0700 All parties have signed document. Signed copies sent to: DENNIS BELITZ and

Nolan Johnson.

2014-04-09 14:11:22 -0700 Document signed by DENNIS BELITZ (dennis.belitz@gmail.com) with drawn

signature. - 66.74.212.135

2014-04-04 10:00:18 -0700 Document viewed by DENNIS BELITZ (dennis.belitz@gmail.com). - 66.74.212.135

2014-04-04 09:25:49 -0700 Document created by Nolan Johnson (nolan.johnson@hpcs.com). - 70.39.177.68

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