CENTRAL MONTANA HEALTH DISTRICT
                                                               JUNK VEHICLE RECYCLING PROGRAM
                                                                                     P. O. BOX 975
                                                                 LEWISTOWN, MONTANA  59457
                                                                           TELEPHONE:   535-7467
                                        RELEASE OF OWNERSHIP OR INTEREST IN MOTOR VEHICLE

 
VEHICLE INFORMATION:   We will haul only vehicles and their component parts.  The crusher
will not accept any trash or tires, which are not mounted on rims.
YEAR______________________________________    MAKE___________________________
MODEL____________________________________     COLOR__________________________
V.I.N.______________________________________    LICENSE PLATE #__________________
Title # ______________________________________         State_______Year ___________

                                                            VEHICLE PARTS INFORMATION

 This vehicle has   (circle the appropriate answers):

                  Motor        Frame        Differential        Transmission        Body        Air

                    Component parts (describe)___________________________________________________

                                                             VEHICLE LOCATION

This vehicle is located in the county of: _______Fergus ________Judith Basin_______Garfield
________Golden Valley _______Meagher ______Musselshell ______Petroleum ______Wheatland

This vehicle is located at: (Give Detailed Directions.  Use back if necessary.)
_____________________________________________________________________________________

                                             READ THIS BEFORE SIGNING
The undersigned, being the legal owner of, or having a legal interest in the vehicle described above, hereby authorizes a duly appointed agent of the County Junk Vehicle program to remove this vehicle to an approved county motor vehicle graveyard.  In the consideration of the foregoing removal, I hereby release all rights, title, and interest in the vehicle to the State of Montana and its agents without payment or compensation.  To the best of my knowledge there is no lien against this vehicle, and I do not possess a certificate of title or Sheriff's certificate of sale for this vehicle.

I agree to hold the State of Montana, the County, and its agents harmless from any claims that may result from the operator of the Junk Vehicle Program, there is no towing charge to me.

    (Please print)
Name of Responsible Party___________________________________Phone____________________
Address_____________________________________________________________________________

Signed____________________________________Yes it is OK to sell this vehicle to an authorized
                                                                                   wrecking facility.
OR
Signed____________________________________This vehicle is to be crushed not sold to an
                                                                                   authorized wrecking facility.

Date________________                                                      Witness______________________________
                                                                                                                (Optional but recommended)

----------------------------------------------------------Office Use Only----------------------------------------------------


Vehicle  #__________________________Date of pick up and delivery__________________