APPLICATION FOR LIEN SALE AUTHORIZATION LIEN SALE UNIT

AND LIENHOLDER’S CERTIFICATION P. O. BOX 932317

A Public Service Agency SACRAMENTO, CA 94232-3170
(Civil Code Section 3071)
A FILING FEE OF $5.00 MUST ACCOMPANY THIS APPLICATION
Current market value of vehicle is OVER $4,000 OR Self-service storage facilities
SUSPENSE RECEIPT AND
PLEASE NOTE: VALIDATION AREA
1. This application must be submitted within 30 days of the date the lien arises. Lien arises on the (Please do not write in this space)
date the owner is billed or 15 days after work or services are completed, whichever occurs first.
2. This form is to be used when conducting a self-service storage facilities lien sale regardless
of vehicle value.
3. This application may not be used for mobilehomes (as described in CVC Section 396)
or vessels, vessel/trailer combinations.
4. *Refer to Civil Code Section 3074 when calculating maximum lien sale cost.
A. VEHICLE DESCRIPTION
LICENSE PLATE NUMBER STATE REGISTERED/EXPIRATION DATE

YEAR MODEL MAKE MODEL BODY TYPE

VEHICLE IDENTIFICATION NUMBER (VIN) ENGINE NUMBER (MOTORCYCLE ONLY)

B. LIEN INFORMATION AS OF:

MONTH/DAY/YEAR: LIEN COST
* TOWING COST

$
REPAIRS

$
$
BAR REGISTRATION (LICENSE NUMBER) DAILY STORAGE RATE STORAGE DUE PARKING VIOLATION BAIL (CVC 22851.1(b))

$ $
DATE OWNER BILLED FOR SERVICES OR STORAGE DATE WORK OR SERVICES COMPLETED DATE OF TOWING AND STORAGE
Authorized by public agency
Abandoned on private property, owner unknown

C. LIEN HOLDER/AGENT INFORMATION

LIENHOLDER’S NAME (PRINT) DAYTIME TELEPHONE NUMBER
( )
STREET ADDRESS CITY STATE ZIP CODE

AGENT ACTING FOR LIENHOLDER (PRINT NAME) REGISTRATION SERVICE NUMBER (REQUIRED) DAYTIME TELEPHONE NUMBER
( )
STREET ADDRESS CITY STATE ZIP CODE

D. PERSON BILLED OR LAW ENFORCEMENT AGENCY AUTHORIZING REMOVAL OF VEHICLE

NAME

STREET ADDRESS CITY STATE ZIP CODE

E. REGISTERED OWNER(S)
REGISTERED OWNER (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

CO-REGISTERED OWNER (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

F. LEGAL OWNER
LEGAL OWNER (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

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LICENSE NUMBER VEHICLE IDENTIFICATION NUMBER (VIN) ENGINE NUMBER (MOTORCYCLE ONLY)

G. INTERESTED PARTIES
NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

NAME (PRINT LAST, FIRST & MIDDLE)

ADDRESS CITY STATE ZIP CODE

H. CERTIFICATION
The names and addresses of the registered owner, legal owner, and all parties known to me to have an interest in the vehicle are
listed on this application.
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
I further certify (or declare) under penalty of perjury that the lien sale was conducted in accordance with the requirements
of California Military and Veterans Code §§407, 408, 409.1, and 409.3, and with the requirements of §§3952, 3953, and
3958 of Title 50 of the United States Code.
LIENHOLDER’S OR AGENT’S (ACTING FOR LIENHOLDER) SIGNATURE DATE

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