1HGCV1F4XMA024600 2021 HOND 8RPR155

BELLEN RAMIREZ AND ALVARO CASTANEDA RAMIREZ JR

INTERINSURANCE EXCHANGE
OF THE AUTOMOBILE CLUB

INTERINSURANCE EXCHANGE OF
THE AUTOMOBILE CLUB

16920 So. Figueroa Street Gardena CA 90248 310-217-5200

BELLEN RAMIREZ

ALVARO CASTANEDA RAMIREZ JR

460 ALAMEDA ST BLYTHE CA 92225

INTERINSURANCE EXCHANGE
BELLEN RAMIREZ AND ALVARO CASTANEDA RAMIREZ JR OF THE AUTOMOBILE CLUB

016233556
 APPLICATION FOR SALVAGE CERTIFICATE OR
NONREPAIRABLE VEHICLE CERTIFICATE
ORIGINAL DUPLICATE 05/27/2021
COMPLETE ONLY SECTION 1 OR SECTION 2 WITH SECTION 3 NONE --------------------------------------------------------------------------------

SECTION 1 – SALVAGE CERTIFICATE

VEHICLE LICENSE NUMBER MAKE OF VEHICLE YEAR VEHICLE IDENTIFICATION NUMBER (VIN)

8RPR155 HOND 2021 1HGCV1F4XMA024600

STATE OF LAST REGISTRATION DATE REGISTRATION EXPIRES CLAIM NUMBER

CA 02/16/2024 016233556
COST/VALUE DATE WRECKED OR DESTROYED DATE STOLEN DATE RECOVERED

12/23/2023
The undersigned certifies that the above described vehicle, for which properly endorsed titling documents are attached, is a total-loss
salvage, and requests the Department of Motor Vehicles to issue a Salvage Certificate. NOTE: A Salvage Certificate cannot be
issued for a stolen vehicle unless the vehicle has been recovered and determined to be a total loss (CVC 11515f)
DATE SIGNATURE OF APPLICANT OR AUTHORIZED AGENT

02/09/2024 X INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

PRINTED NAME OF INSURANCE COMPANY OR APPLICANT DL OR ID NUMBER (IF APPLICABLE)

INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

STREET ADDRESS CITY STATE ZIP CODE

16920 SO. FIGUEROA ST. GARDENA CA 90248

PRINTED NAME OF AGENT (IF APPLICABLE) OCCUPATIONAL LICENSE NUMBER (IF APPLICABLE)

SECTION 2 – NONREPAIRABLE VEHICLE CERTIFICATE

A vehicle declared nonrepairable may not be titled or registered for use on the roads or highways of California. A “nonrepairable
vehicle certificate” is a vehicle ownership document issued to the owner of a nonrepairable vehicle. Ownership of the vehicle
may only be transferred two times on a nonrepairable vehicle certificate. (CVC 432).
VEHICLE LICENSE NUMBER MAKE OF VEHICLE YEAR VEHICLE IDENTIFICATION NUMBER (VIN)

STATE OF LAST REGISTRATION DATE REGISTRATION EXPIRES CLAIM NUMBER

COST/VALUE DATE WRECKED OR DESTROYED DATE STOLEN DATE RECOVERED

Surgical Strip Burned Hulk Owner Declared (CVC 431)

The undersigned certifies that the above described vehicle, for which properly endorsed titling documents are attached, is a
nonrepairable vehicle, and requests the Department of Motor Vehicles to issue a Nonrepairable Vehicle Certificate.
DATE SIGNATURE OF APPLICANT OR AUTHORIZED AGENT

02/09/2024 X INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

PRINTED NAME OF INSURANCE COMPANY OR APPLICANT DL OR ID NUMBER (IF APPLICABLE)

INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

STREET ADDRESS CITY STATE ZIP CODE

16920 SO. FIGUEROA ST. GARDENA CALIFORNIA 90248

PRINTED NAME OF AGENT (IF APPLICABLE) OCCUPATIONAL LICENSE NUMBER (IF APPLICABLE)

SECTION 3 – CERTIFICATION OF LICENSE PLATE DISPOSITION

The license plates assigned to this vehicle:
Are being surrendered …………….…….Plates surrendered: one two
Have been lost
Have been destroyed (Occupational Licensees Only) Occupational License Number ___________________________
Plate with owner – Retained by owner for reassignment
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
DATE SIGNATURE

02/09/2024 X INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

REG 488C (REV. 8/2008) WWW
 APPLICATION FOR SALVAGE CERTIFICATE OR
NONREPAIRABLE VEHICLE CERTIFICATE
ORIGINAL DUPLICATE 05/27/2021
COMPLETE ONLY SECTION 1 OR SECTION 2 WITH SECTION 3 NONE --------------------------------------------------------------------------------

SECTION 1 – SALVAGE CERTIFICATE

VEHICLE LICENSE NUMBER MAKE OF VEHICLE YEAR VEHICLE IDENTIFICATION NUMBER (VIN)

8RPR155 HOND 2021 1HGCV1F4XMA024600

STATE OF LAST REGISTRATION DATE REGISTRATION EXPIRES CLAIM NUMBER

CA 02/16/2024 016233556
COST/VALUE DATE WRECKED OR DESTROYED DATE STOLEN DATE RECOVERED

12/23/2023
The undersigned certifies that the above described vehicle, for which properly endorsed titling documents are attached, is a total-loss
salvage, and requests the Department of Motor Vehicles to issue a Salvage Certificate. NOTE: A Salvage Certificate cannot be
issued for a stolen vehicle unless the vehicle has been recovered and determined to be a total loss (CVC 11515f)
DATE SIGNATURE OF APPLICANT OR AUTHORIZED AGENT

02/09/2024 X INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

PRINTED NAME OF INSURANCE COMPANY OR APPLICANT DL OR ID NUMBER (IF APPLICABLE)

INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

STREET ADDRESS CITY STATE ZIP CODE

16920 SO. FIGUEROA ST. GARDENA CA 90248

PRINTED NAME OF AGENT (IF APPLICABLE) OCCUPATIONAL LICENSE NUMBER (IF APPLICABLE)

SECTION 2 – NONREPAIRABLE VEHICLE CERTIFICATE

A vehicle declared nonrepairable may not be titled or registered for use on the roads or highways of California. A “nonrepairable
vehicle certificate” is a vehicle ownership document issued to the owner of a nonrepairable vehicle. Ownership of the vehicle
may only be transferred two times on a nonrepairable vehicle certificate. (CVC 432).
VEHICLE LICENSE NUMBER MAKE OF VEHICLE YEAR VEHICLE IDENTIFICATION NUMBER (VIN)

STATE OF LAST REGISTRATION DATE REGISTRATION EXPIRES CLAIM NUMBER

COST/VALUE DATE WRECKED OR DESTROYED DATE STOLEN DATE RECOVERED

Surgical Strip Burned Hulk Owner Declared (CVC 431)

The undersigned certifies that the above described vehicle, for which properly endorsed titling documents are attached, is a
nonrepairable vehicle, and requests the Department of Motor Vehicles to issue a Nonrepairable Vehicle Certificate.
DATE SIGNATURE OF APPLICANT OR AUTHORIZED AGENT

02/09/2024 X INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

PRINTED NAME OF INSURANCE COMPANY OR APPLICANT DL OR ID NUMBER (IF APPLICABLE)

INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

STREET ADDRESS CITY STATE ZIP CODE

16920 SO. FIGUEROA ST. GARDENA CALIFORNIA 90248

PRINTED NAME OF AGENT (IF APPLICABLE) OCCUPATIONAL LICENSE NUMBER (IF APPLICABLE)

SECTION 3 – CERTIFICATION OF LICENSE PLATE DISPOSITION

The license plates assigned to this vehicle:
Are being surrendered …………….…….Plates surrendered: one two
Have been lost
Have been destroyed (Occupational Licensees Only) Occupational License Number ___________________________
Plate with owner – Retained by owner for reassignment
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
DATE SIGNATURE

02/09/2024 X INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

REG 488C (REV. 8/2008) WWW
Your liability for this vehicle or vessel may not be released if you submit illegible information.
PRINT YOUR CHARACTERS IN CAPITAL LETTERS USING BLACK OR BLUE INK – READ INSTRUCTIONS ON REVERSE SIDE
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0 1 2 3 4 5 6 7 8 9

NOTICE OF RELEASE OF LIABILITY

DMV MICROGRAPHICS USE ONLY MAIL THIS FORM TO DMV

A. BUYER(S) TRUE FULL NAME (LAST) (FIRST) (MIDDLE) B. IF DEALER CHECK BELOW

I N T E R I N S E X C H O F A U T O C L U B
D. ODOMETER
C. BUYER’S ADDRESS READING
1 6 9 2 0 S O . F I G U E R O A S T ,
F. DATE OF SALE
E. CITY STATE ZIP CODE MO . DAY YR.

G A R D E N A C A 9 0 2 4 8 -
G. SELLER’S TRUE FULL NAME (LAST) (FIRST) (MIDDLE)

R A M I R E Z B E L L E N
H. SELLER’S ADDRESS I. SELLING PRICE

4 6 0 A L A M E D A S T
J. CITY STATE ZIP CODE K. SELLER’S SIGNATURE

B L Y T H E C A 9 2 2 2 5 - x.
L. VEHICLE ID/VESSEL HULL NUMBER M. YR. MODEL N. MAKE/BUILDER O. PLATE/CF NUMBER

1 H G C V 1 F 4 X M A 0 2 4 6 0 0 2 0 2 1 H O N D 8 R P R 1 5 5
REG 138 (REV. 8/98) WWW
To Whom it may concern:

Owner: BELLEN RAMIREZ

Claim # 016233556
Account #: 0
Mileage: 0

Upon receipt of payment in the amount of $ due on my finance account covering my

2021 HOND, identification number 1HGCV1F4XMA024600, you are instructed and authorized
to deliver the Interinsurance Exchange of the Automobile Club of Southern California, all
papers and evidence of title for this vehicle properly endorsed and released.

Please forward the requested documents to:

ACSC
16920 S Figueroa St
Carson, Ca 90248

Very Truly Yours,

Signature:

Date:
 APPLICATION FOR VEHICLE LICENSE FEE REFUND:
Unrecovered Total Loss Vehicle – Complete Part A
Unre
Constructive Total Loss OR Nonrepairable Vehicle – Complete Part B
LICENSE PLATE NUMBER VEHICLE ID NUMBER YEAR MODEL MAKE

8RPR155 1HGCV1F4XMA024600 2021 HOND

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

Name and location of Police Agency

Registered Owner(s) of Record
PRINT TRUE FULL NAME 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

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 the 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 sate of California that the foregoing is true and correct.
SIGNATURE OF INDIVIDUAL OR COMPANY’S AUTHORIZED EMPLOYEE DATE DAYTIME PHONE NUMBER

X ( )
PART B – CONSTRUCTIVE TOTAL LOSS OR NONREPAIRABLE VEHICLE
Vehicle was wrecked, destroyed, or damaged by a single event on this date: MO. DA. YR.

1. Registered Owner(s) of Record completes this part (If jointly owned, all owners must sign):
PRINT TRUE FULL NAME PRINT TRUE FULL NAME

BELLEN RAMIREZ ALVARO CASTANEDA RAMIREZ JR

ADDRESS CITY STATE ZIP CODE

460 ALAMEDA ST BLYTHE CA 92225

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

X ( )
SIGNATURE DATE DAYTIME PHONE NUMBER
X ( )
2. Individual or Company who paid for loss of vehicle (owner of the salvage value of vehicle):
PRINT TRUE FULL NAME

INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB

ADDRESS CITY STATE ZIP CODE

16920 S. FIGUEROA STREET GARDENA CA 90248

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

X ( )
WHERE TO MAIL THE REFUND REQUEST
Department of Motor Vehicles. P.O. Box 942869, Sacramento, CA 94269-0001
NONE ------------
REG 65 (REV. 4/2007) WWW 016233556 ----------------------