Please read the Sale of Motor Vehicles Compensation Fund Guide before completing this form
If completing this form by hand, please complete details in block letters using a black or blue pen.  
Send or deliver application to the address below.
TO: The Registrar of Motor Vehicle Dealers
Applicant’s Details	
Name of 
Applicant	     	Date of Birth           /          /	
Address 	
	   	   	   	   	   	      Postcode                   	Telephone number – 
	Home		   
	Business		   
	Mobile		   	
Email address       	Occupation       	
Trade Owner’s Details	
Name of motor vehicle dealer
     	LMVD (license number of motor vehicle dealer)
     	
Address		   	   	   	      Postcode                   	
Vehicle Details	
Registration number of motor car        	
Make and model of motor car (eg 1998 Holden Commodore)        	
Transaction Details	
Date of transaction            /          /	Purchase price - $      	
Have you taken steps to resolve the claim? 	
   Yes       No,       If yes, please provide a description 
	   	   	   	   	   	   	
Grounds for Claim/Description of Circumstances giving rise to claim	
I believe that I am entitled to compensation for the following reasons (give a full description of events that led up to this claim, your dealings with the motor vehicle dealer and what attempts were made to resolve the matter with the motor vehicle dealer). Attach separate sheet(s) if you need more space.
	   	   	   	   	   	   	   	   	   	
Details of Claim	
Amounts Claimed

Total amount $                                        	Itemised amount $
	     	$                   
	     	$                   
	     	$                   
	     	$                   	
Document Checklist	
   contract of sale	
   invoices
   finance agreement	
   receipts and cheques (or cheque butts)
   independent mechanical reports	
   quotes and invoices relation to repair work
   information or certificates from Register of Encumbered Vehicles (REVS)
   correspondence between you and the motor vehicle trader, or solicitors, or to you from finance companies
   a warrant authorising the seizure by police of a motor car suspected of being stolen
   any other relevant documents. 
If you do not have relevant documents, please briefly explain why here.
	   	   	
Statutory Declaration	

I                                                                                of                                                                      : 
	[Insert Full Name(s)]	[Insert Address]
do solemnly and sincerely declare as follows:
The statements made by me in this application and attachments are true in every particular and I make this solemn declaration by virtue of the Statutory Declarations Act 1959, as amended and subject to the penalties provided by that Act for the making of false declarations, conscientiously believing the statements contained in this declaration to be true in every particular.

Declared at  .............................................................................
this  ...........................................  day of  ..................................  20 .........
before me:  .............................................................................
	Justice of the Peace/Solicitor

	Declarant’s Signature	Justice of the Peace/Solicitor Signature	

The Office of Regulatory Services (which includes the Registrar of Motor Vehicle Dealers, Deputy Registrar of Motor Vehicle Dealers and Inspectors) is committed to the responsible and fair handling of personal information, consistent with the Privacy Principles of the Privacy Act 1988 (Cth).