VIRGINIA MOTOR VEHICLE DEALER BOARD TRANSACTION RECOVERY FUND JUDGMENT CLAIM REQUEST

INSTRUCTIONS:

1. An attested copy of the final judgment order;

2. Copies of all pleadings filed by either party

3. A MVDB Consumer Assistance Request form or written statement of the facts of fraud or fraudulent representative by the dealer or salesperson which forms the basis of this claim request and for which judgment was obtained.

1. Claimant’s Name(s):________________________________________________________________________________

________________________________________________________________________________________________

Address_______________________________________________________________________________________

City/State______________________________________________________________Zip: ____________________

Telephone Numbers: (Business)________________________________(Home)________________________________

2.Attorney’s Name (If none, write “none”):________________________________________________________________

Address________________________________________________________________________________________

City/State:______________________________________________________________Zip:_____________________

Telephone Number:________________________________________________________________________________

If claim is against dealer, complete Section 3A. If claim is against dealer and/or salesperson, complete Section 3A & 3B.

3A. Dealer’s Trade

Name:______________________________________________________________________________

Dealer’s MVDB License Number (if known):_____________________________________________________________

Address: ________________________________________________________________________________________

City/State:____________________________________________________________ Zip:______________________

Telephone Number:_______________________________________________________________________________

3B. Salesperson’s Name:______________________________________________________________________________

  Salesperson’s MVDB License Number (if known):________________________________________________________

Home Address:__________________________________________________________________________________

City/State:____________________________________________________________ Zip:______________________

4. Date of Judgment:__________________________

Amount of Judgment: $_________________________

Amount paid by Judgment Debtor: $_________________________

Amount of Claim (not to exceed $15,000): $_________________________

5. To your knowledge, has the Dealer or Salesperson filed for Bankruptcy? Yes___    No:__________

If yes, in what district?____________________________________________________________________________

If yes, have you filed a complaint in the bankruptcy court to determine the dischargeability of the debt?

Yes:_________     No:__________

If yes, what was the result of this complaint?___________________________________________________________

       _____________________________________________________________________________________________

    _______________________________________________________________________________________________

         _______________________________________________________________________________________________

6.Have you conducted debtor interrogatories:Yes:_________    No:___________

If yes, list any assets revealed by these interrogatories (if none – write “none”):

   ______________________________________________________________________________________________

List any actions you have taken for the sale or application of the disclosed assets (if non – write “none”):

         _______________________________________________________________________________________________

List any amounts realized from these actions (if none – write “none”):

         _______________________________________________________________________________________________

If no, explain:___________________________________________________________________________________

7.Are you licensed or registered as a dealer in Virginia?: Yes_________     No:___________

Are you a licensed salesperson in Virginia?: Yes_________     No:___________

If yes, cite your dealer license or registration number and/or salesperson number:

NOTARIZED STATEMENT:SIGNATURE MUST BE WITNESSED BY A NOTARY

OATH:I/We swear that I am/are the claimant(s): I/We have read and/or understand the contents of the claim; the contents are true and complete to the best of My/Our knowledge and belief.

Print Name(s):______________________________________________________________________________________

_____________________________________________________________________________________

____________________________________________________________________________

______________________________________________________________________________________

THE FOLLOWING CERTIFICATE MUST BE EXECUTED BY A NOTARY PUBLIC OR OTHER COURT OFFICIAL AUTHORIZED TO TAKE ACKNOWLEDGEMENTS.

State of _____________________________ City/County of _________________________ on this day ____________
                                                                                                                                                                            Date

Whose name is signed to the foregoing instrument, personally appeared before me, acknowledged the foregoing signature to be his, and have been duly sworn by me, made oath that the statements made in the said instrument are true.

My commission expires ____________________________________ Signature _________________________________

MVDB-13 (REV 12//95)