Eu,_______________________________________________________________________,
portador do RG_______________________________, CPF___________________________,
residente na ________________________________________________________________
_____________________________________, n___________, complemento___________,
bairro ______________________________________, CEP__________________________,
proprietrio
do
veculo
placa_________________________________,
Renavam__________________________________________________________________.
Furto
Perda
Dano
_____________________________________
(Assinatura)
Unidade
(carimbo e assinatura)
Vistoria
(carimbo e assinatura)
Lacrao
(carimbo e assinatura)