
NAME
AMOUNT OF CHARGE IMPOSED BY TOWER
(City or Town)
(No. & Street)
LOCATION VEHICLE ABANDONED
VEHICLE IDENTIFICATION NUMBER
MAKE/MODEL
YEAR
INSTRUCTIONS
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I
MUNICIPALITY REPORT OF ABANDONED MOTOR VEHICLE
H-109 REV. 3-2018
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
TITLE SECTION
60 STATE STREET, WETHERSFIELD, CT 06161
On The Web At ct.gov/dmv
Complete SECTION A for each abandoned motor vehicle which is determined to be: (a) valued at $500.00 or less; (b) unusable as a motor vehicle; and (c)
without a valid marker plate (C.G.S. §14-150(d)).
Submit original form to the Department of Motor Vehicles within 48 HOURS of the time the motor vehicle is taken into custody.
Retain a copy and complete SECTION B when vehicle ownership is transferred. Submit copy to transferee in lieu of a vehicle title.
1.
2.
3.
TO: DEPARTMENT OF MOTOR VEHICLES, TITLE SECTION, 60 STATE STREET, WETHERSFIELD, CT 06161
SECTION A - TO BE COMPLETED WHEN MUNICIPALITY TAKES POSSESSION OF MOTOR VEHICLES
NAME OF MUNICIPALITY (in which title is vested)
DATE AND TIME VEHICLE TAKEN INTO CUSTODY
NAME OF OFFICER OR INSPECTOR (who determines vehicle meets C.G.S. §14-150(d))
BADGE NUMBER
VEHICLE
INFORMATION
BUSINESS NAME & ADDRESS OF TOWER
$
I hereby certify the above abandoned vehicle meets the specifications of C.G.S. §14-150(d) and that the vehicle identification
number has been checked through NCIC.
DEPARTMENT NAME
AUTHORIZED SIGNATURE OF MUNICIPAL OFFICIAL
DATE SIGNED
X
SECTION B - TO BE COMPLETED WHEN MUNICIPALITY TRANSFERS OWNERSHIP OF MOTOR VEHICLE TO JUNKYARD
ADDRESS
(No. & Street)
(City or Town)
(State)
(Zip Code)
TRANSFEREE
INFORMATION
DEPARTMENT NAME
AUTHORIZED SIGNATURE OF MUNICIPAL OFFICIAL
X
DATE SIGNED