NHTSA Form 1077 CARS Compliance Inspection Form

OMB No. 2127 – XXXX

Expiration Date: XX/XX/XXX

Consumer Assistance to Recycle and Save (CARS)

Compliance Inspection Checklist

(For internal use only)

FRANCHISE INFORMATION

Dealer Name

Address

Phone Number

Inspection Date

Dealer Rep. Interviewed

DOT Inspector

L isted on CARS.gov Yes No F ranchise agreement Yes No S tate Dealer’s License Yes No

Notes

TRANSACTION INFORMATION

P roof of Title Yes No P roof of Registration (1 yr) Yes No T itle and Registration in same name Yes No S alvage Auction or Disposal Facility Cert. Yes No T itle marked “Junk Automobile CARS.gov” Yes No “ F uel economy.gov side-by-side comparison Yes No

P roof of Insurance (1 yr) Yes No P urchaser Identification Yes No S ale/lease agreement Yes No O EM certificate of origin Yes No C ARS purchaser survey Yes No A ppendix A certification Yes No

Notes

SALVAGE AUCTION and/or DISPOSAL FACILITY

Name

Address

Phone

Name

Address

Phone

NEW VEHICLE

Make

Model

Model Year

VIN

Is the base MSRP $45,000 or less compared against same model vehicle?

Y es No

TRADE-IN VEHICLE

Make

Model

Model Year

VIN

Location of trade-in vehicle

N ew Vehicle Dealer

S alvage Auction

D isposal Facility

Photographs

V ehicle Placard

¾ View of Vehicle

W indshield VIN

Is the engine disabled?

Y es No

If operable, video vehicle while running

Notes Section Description

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.

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2127-XXXX. Public reporting for this collection of information is estimated to be approximately XX minutes per response including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

NHTSA Form 1077