1. 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

2. VEHICLEA/ESSELTRANSFERANDREASSIGNMENTFORMA Public Service Agency
INSTRUCTIONSON REVERSESIDE- ALL SIGNATURESMUSTBE IN INK _ PHOTOCOPIESNOTACCEPTED
ThisformlsnottheownershipcertifhaE.Itmustaccompanythetittingdocumentor
Applicationfor DuplicateTitle.For Car Buyer'sBill ot Rights,visitwww.dmv.ea.gov. I
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sell,transfer,and deliverthe abovevehicle/vessel
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PRINTSELLER'SNAME(S)
fortheamountofPRINTBUYER'SNAME(S)
DAY YEAR
(e.9.,parents,spouse,friend,etc.)lf thiswasa gift,indicaterelationship:
sEciioNs! odoMErER'p|sctosungsiAtEUEryi,(w.ia'i;t:uiieaee,isnit*oc#
Federaland StateLaw requiresthatyou statethe mileageupon transferof ownership.Failureto completeor providing
a falsestafementmay resultin finesandlor imprisonment.
WARNING_ODOMETERDISCREPANCY
flOdometerreadingisNOTtheactualmileage n ViteageEXCEEDStheodomerermeghgnig,?!linilS
Explainedometerdiscrepancy:
LICENSEPLAf,VCF NO:
SIGNATUREREOUIREDBY PERSON
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SIGNATUREREOUIREDBY PERSONAPPOINTINGPOWEROFATTORNEY
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I.acknowledgetlg ?dory_eterreadingaq! thefactsof thetranster.lcertity(or dectare)under penattyot perjuryunder
the lawsof theStafeof Calitorniathat the toreqoinqis trueand correct.
BUYER'SSECTION
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I certify(or declare)under penaltyof perjury under the lawsof theStafeof Californiathat theforegoingis true anct
correct.
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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

3. 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
influence of alcohol or drugs (VC §23152, §23153, or §23103). I did not plea bargain a reduced sentence for driving under the influence 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 NUMBER
X ( )
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 THE
DEPARTMENT.
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 94269-0001
REG 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 Record
PRINT 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

4. 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-Avehicle 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 Certificate
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
Certificate must be issued for this vehicle before a refund will be processed. §10902 R&T.
REG 65 (REV. 4/2007) WWW

5. 7CMF419 3VW2K7AJ6DM449783 2013 VOLKSWAGEN7CMF419 VOLKSWAGEN3VW2K7AJ6DM449783 2013

6. 04/09/2014

7. KNTU86JYAL4WPLV5E26EDD
DENNIS BELITZ
Party ID: 92M4XKINAIRP9KVUEULUGL
IP Address: 66.74.212.135
VERIFIED EMAIL: dennis.belitz@gmail.com
Multi-Factor
Digital Fingerprint Checksum d8a1f1353e9d0d4c9f4b0b6f245e6e0e3da7857b
Timestamp Audit
2014-04-09 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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