Free MDOS Form - Michigan

Bureau of Regulatory Services Michigan Department of State Lansing, Michigan 48918

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MICHIGAN VEHICLE DEALER CLOSEOUT STATEMENT
I, ________________________________________________________________ as _________________________________________
(Name) (Name of Dealership) (Title)

of ____________________________________________________________________ , hereby certify that I have discontinued business as a Michigan Vehicle Dealer, under Dealer License No. ______________ , effective _____________________ .
(Date)

I further certify that I have disposed of all vehicles that were in our inventory under this license. These have been: Sold at retail; and/or Sold at wholesale; and/or Titled and registered to me with the proper amount of sales tax paid. I further certify that I have surrendered: My dealer wall license; and All dealer plates (listed below) assigned under this license; and All remaining temporary registrations. These have been surrendered to the following representative of the Michigan Department of State: The Secretary of State branch office located at _____________________________________ on _____________ .
(Location) (Date)

OR Bureau of Legal and Regulatory Services Investigator ________________________________ on ____________ .
(Name of Investigator) (Date)

OR The Bureau of Legal and Regulatory Services, Lansing, Michigan on __________________ .
(Date)

List below all dealer plates that were assigned to your dealership and have been surrendered to the above:

I am presently unable to locate plate number(s) ______________________________________________________________ . These dealer plates will be surrendered immediately to the Department of State, should they be recovered. I certify that I have reported these plates as lost or stolen to a local police agency. My records will be available for inspection at _______________________________________________________________ .
(Address) (City)

I certify that I am surrendering my dealer license as of this date, and that all the statements I have made herein are true and accurate to the best of my knowledge. I further certify I understand that, according to Section 257.248 of the Michigan Vehicle Code, selling 5 or more vehicles in a calendar year meets the definition of a dealer. A fine of $5,000 for a first offense and $7,500 for a second offense of selling vehicles without a dealer license can be imposed for acting as a dealer without an active Michigan vehicle dealer license.

Signed, X _________________________________________________________________
(Signature and Title)

_____________________
(Date) (Rev. 9/2003)