Form VTR-61
(Rev. 11/09)
Page 1 of 2
Rebuilt Vehicle Statement
TYPE OR PRINT
Instructions
w All information must be complete.
w The vehicle owner or authorized agent must complete the Owner Statement below.
w The person who repaired, rebuilt, reconstructed or assembled the vehicle must complete the information on page 2 if
component parts were used.
w If rebuilt by the owner and component parts were used, the owner must complete both the Owner Statement below
and the Rebuilder Statement on page 2.
w Pages 1 and 2 of this statement must be submitted with your title application.
Vehicle Information
Year
Make
Model
Vehicle Identification Number
Body Style
Document/Title # (If Applicable)
Inspection Information
An authorized inspection station must inspect the
vehicle after it has been rebuilt
(not required for title only transactions)
(Rebuilt) Vehicle Inspection Sticker Number
Expiration Date
Date of Inspection
Explanation of Repairs
Explanation by rebuilder (owner or person who rebuilt the vehicle) as to what was done to assemble, rebuild, reconstruct or alter the vehicle for which
title is sought:
IF COMPONENT PARTS HAVE BEEN USED, PAGE 2 MUST BE COMPLETED.
Owner Statement
This statement is to certify that:
w I am the legal and rightful owner of the vehicle described above.
w The vehicle has been rebuilt, repaired, reconstructed or assembled.
w The vehicle identification number (VIN) disclosed is the same as the VIN affixed to the motor vehicle.
Owner's Name
Owner’s Signature
Mailing Address
Date
City, State, Zip
WARNING! TRANSPORTATION CODE §501.155 PROVIDES THAT FALSIFYING INFORMATION ON ANY REQUIRED DOCUMENT
IS A THIRD-DEGREE FELONY.
Form VTR-61 (Rev. 11/09)
Page 2 of 2
IF THE VEHICLE HAS BEEN REBUILT, RECONSTRUCTED OR ASSEMBLED FROM COMPONENT PARTS, COMPLETE THE FOLLOWING:
Component Part
Attach evidence of ownership
(bill of sale and/or title)
Origin Of Component Parts/Purchased From:
Name
Address
Component Part Number
City, State, Zip
(Required)
Engine
Frame
Body
v Specify location of component parts replaced: Right (RT) Left (L) Front (F) Rear (R) Right Front (R F) Left Front (L F) Right Rear (R R) Left Rear (L R)
Component Part
Submit any bills of sale for
component parts (if available)
Origin Of Component Parts/Purchased From:
Name
Address
Component Part Number
City, State, Zip
(If Available)
Transmission
Fender(S) v
Hood
Door(S) v
Bumper(S) v
Quarter Panel(S) v
Tailgate/Hatchback/Deck Lid
Pickup Cargo Box (Truck, Less Than
One Ton)
Truck Cab
Roof Or Floor Pan (Passenger
Vehicle, If Separate From Body)
This statement is to certify that I:
Rebuilder Statement
w rebuilt, repaired, reconstructed or assembled the vehicle described on page 1.
w purchased or came into possession of all the component parts listed above in a legal and lawful manner and in accordance with the provisions of Transportation Code,
Chapter 501.
Rebuilder's Name
Mailing Address
City, State, Zip
Rebuilder’s Signature
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