NHTSA 1071 Transaction Form

OMB No. 2127-XXXX

Expiration Date: mm/dd//yyyy

D RAFT

This is a physical representation of a web-based form

Transaction Form

Consumer Assistance to Recycle and Save (CARS) Program

CARS Record #		CARS Dealer ID					Transaction Date
System Provided		System Provided					System Provided
Purchaser Information
Purchaser ID Number (Individual or Business)			Co-Owner ID Number					Purchaser Identification State
Purchaser Contact Information
Full Name (Last Name, First Name, MI)
Address City, State, 9-Digit Zip Code
Trade-In Vehicle Information
Make	Model					Model Year
Trade-In VIN	Vehicle EPA Category Number (Passenger, 1, 2, 3)					Insurance Start Date
Registered State	Start Date of Registration					Registration Expiration Date
Titled State	Odometer Reading					EPA Combined Mileage
Trade-In Vehicle Description:					NMVTIS Last Update Date (Hide from View)
New Vehicle Information
Make	Model					Model Year
VIN	EPA Combined Mileage					Vehicle EPA Category Number (Passenger, 1, 2, 3)
Manufacture Suggested Retail Price (MSRP):				New Vehicle Description:

CARS Record #	CARS Dealer ID			Transaction Date
System Provided	System Provided			System Provided
Vehicle Disposition Data
Entity Transferred To: (Name, Address, City, State, Zip Code, Phone Number)
Vehicle been sent directly to an End of Life (EOL) processing facility (Y/N) or Vehicle has it been turned over for further processing (salvage auction facility; pick a part)? (Y/N)
Transaction Data
Date of Sale:		Transaction Request Amount ($3500 or $4500)
Supporting Documentation
The following attachments are required to be provided to the CARS program at the time of voucher submittal in electronic format (PDF, TIF, JPEG): Trade-In Title (Front / Back) or other evidence of ownership Trade-In Proof of Insurance Trade-In Proof of Registration Deal Sheet and Certifications Certification from Disposal or Transfer Entity Copy of Purchaser(s) Identification (Individual(s) or Business) Manufacture Certificate or Origin (MCO) / Manufacture Statement of Origin (MSO) Fuel Economy.gov Side-By-Side Comparison Purchaser Survey (optional) Miscellaneous Attachment (Please name accordingly based on NHTSA Guidance provided at http://www.cars.gov/dealersupport/)

CARS Record #	CARS Dealer ID	Transaction Date
System Provided	System Provided	System Provided
Certification of Information
WARNING This is a legal document that contains certifications under penalty of law. There are significant civil and criminal penalties for submitting false information. Please read each certification and ensure that the information that you are certifying by signing this document is based on personal knowledge and is, to the best of your knowledge and belief, true, accurate, and complete. The person submitting this transaction as “Dealer” does so with personal knowledge and certifies under penalty of law that: Registration in the CARS Program The dealer has been approved as a registered dealer under the CARS program. The dealer has a currently active business license under State law to operate a new automobile dealership. The dealer has a currently active franchise agreement with an original equipment manufacturer to sell new automobiles. Purchaser and Trade-In Vehicle Eligibility for the CARS Program I have verified the identity of the person signing this document under “Purchaser” (hereinafter simply “Purchaser”). I have verified that the trade-in vehicle is in drivable condition, and I or an employee under my direction or supervision has operated the trade-in vehicle to confirm that the trade-in vehicle is in drivable condition. I have verified that the trade-in vehicle has been continuously insured for a period of not less than one (1) year prior to the date of this transaction. I have verified that the Purchaser has been the registered owner of the trade-in vehicle continuously for a period of not less than one (1) year prior to the date of this transaction. I have observed the trade-in vehicle’s date of manufacture (both month and year) as it appears on the trade-in vehicle’s safety standard certification label, and have verified that the trade-in vehicle was manufactured less than 25 years before the date of the trade-in. I have verified that the trade-in vehicle’s fuel economy is eligible for the CARS program. New Vehicle Eligibility for the CARS Program The new vehicle is being purchased or, in the case of a lease, leased for a period of not less than five (5) years. I have verified that the CARS program credit amount requested (i.e., either $3,500.00 or $4,500.00, as applicable) corresponds to the difference between the trade-in vehicle’s fuel economy and the new vehicle’s fuel economy under the requirements of the CARS program. The new vehicle has a base manufacturer’s suggested retail price (MSRP) as shown on the Monroney label affixed to the new vehicle of $45,000 or less (exclusive of any accessories, optional equipment, taxes or destination charges). Transaction Conforms to the Requirements of the CARS Program I have reduced the price of the new vehicle that is being purchased or leased by the CARS Program credit amount requested (i.e., either $3,500.00 or $4,500.00, as applicable). I have disclosed to the Purchaser the best estimate of the scrappage value of the trade-in vehicle. I have retained no more than $50.00 of the scrappage value as payment for any of the dealer’s administrative costs in connection with this CARS transaction. I have not charged the Purchaser any additional fees for participating in the CARS program in this transaction. I have applied the credit under the CARS program in addition to any other rebate or discount advertised by the dealer or offered by the manufacturer for the new vehicle, and have not used the CARS program credit to offset any such other rebate or discount. I have not reduced the value of the CARS program credit amount requested (i.e., either $3,500.00 or $4,500.00, as applicable) by any other available Federal, State, or local incentive or a State-issued voucher for the purchase or lease of a new fuel efficient automobile. Disposal of the Trade-in Vehicle The trade-in vehicle has not been, and will not be, sold, leased, exchanged or other disposed of for use as an automobile in the United States or in any other country. I have either: (a) rendered the engine block of the trade-in vehicle inoperable under the procedures of the CARS Program prior to further transfer of the trade-in vehicle; or, (b) this transaction occurred prior to July 24, 2009, and I have submitted to NHTSA the necessary proof as attachments under Miscellaneous Documents that the engine block has been crushed or shredded. I have transferred or will transfer the trade-in vehicle, including the engine block, to either: (a) a CARS program participating disposal facility that will crush or shred the trade-in vehicle; or, (b) to a participating salvage auction that will transfer the vehicle to such a disposal facility. I have provided the disposal facility and/or salvage auction information and written notice that it is responsible for the removal and appropriate disposition of refrigerants, antifreeze, lead products, mercury switches, and such other toxic or hazardous vehicle components prior to the crushing or shredding of an eligible trade-in vehicle, in accordance with all applicable Federal and State requirements. I certify under penalty of law that: I have authority to execute this document, I have read each of the foregoing certifications, I understand that payment of the CARS program credit amount is conditioned on compliance with these certifications, This document, and all attachments, were either prepared by me or prepared under my direction or supervision, The information set forth in this document, and all attachments, is based on personal knowledge and is, to the best of my knowledge and belief, true, accurate, and complete, I am aware that there are significant penalties for submitting false information, including the possibility of civil penalties under the CARS program, suspension or revocation of continued participation in the CARS program, as well as fines and/or imprisonment. Privacy Act Statement This notice is provided pursuant to the Privacy Act of 1974, 5 USC § 552a: This information is solicited under the authority of Public Law 111-32, 123 Stat. 1859. Furnishing the information is voluntary, but failure to provide all or part of the information may result in disapproval of your request for a credit on this purchase or lease transaction under the Cars Program. The principal purposes for collecting the information are to determine if purchase or lease transactions are eligible for credits under the CARS Program, to ensure proper disposal of trade-in vehicles, to prevent, identify and penalize fraud in connection with the Program, and to update an existing government database of Vehicle Identification Numbers. If you complete the optional survey, the survey information will be used to report to Congress on the Program. Other routine uses are published in the Federal Register at 65 F.R. 19476 (April 11, 2000), available at: www.dot.gov/privacy.

Version 7/16/2009

NHTSA Form 1071 2/3/2021 Page 1 of 5