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TOTAL LOSS STATEMENT North Dakota Department of Transportation Motor Vehicle Division 608 E Boulevard Ave Bismarck ND 58505-0780 Telephone 701 328-2725 Web site www. dot. nd. gov SFN 53386 Rev. 07-2009 THIS WILL CERTIFY THAT Owner Daytime Telephone Number Address City State Zip Code received compensation for the following vehicle Year Make Vehicle Identification Number Month Day which was a total loss as a result of an accident occurring on Claim.

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