Whose form is it? A licensed dealer's or repairer's - and it exists to say, in a professional opinion the department will accept, that a car is worth less than $1,500. It is on this page because that sentence is worth money to a seller in the other direction: it is the document that gets a rough, stripped, burnt or rotten Connecticut vehicle valued honestly instead of taxed and treated as though it were roadworthy. You cannot sign one, but you can ask for one.
Written against H-116 (Rev 6-2025), issued under A Connecticut DMV Dealers and Repairers Section form, subscribed under penalty of false statement per s. 14-110 and s. 53a-157b.
Do not confuse a low valuation with a salvage brand. This form is an opinion about what a vehicle is worth; a salvage title is a legal status created when an insurance company declares a total loss, and the department warns that it is illegal to operate a salvage vehicle upon any road in Connecticut.
Two documents, and they are not the same thing. Take the blank H-116 from the portal.ct.gov copy so you get the revision that is current today.
This is the actual H-116, rendered from the PDF the Connecticut Department of Motor Vehicles publishes and completed end to end: letterhead, every field, and the blocks at the foot.
Amber — you write it
Grey — not yours to fill
Numbered — explained below
Filled in as a licensed repairer would complete it on a rotten 2004 Malibu. The six unticked condition boxes are greyed, and so is everything else, because none of this form belongs to the vehicle's owner. Every name and number here is invented for the sample.
Field by field
Every line, in the order you meet it
1
Dealers only
Vehicle Make and Model
Two of the four identification boxes across the top row.
Watch out: Nothing in this row is yours to complete. Bring the registration certificate to the repairer and let them copy it.
2
Dealers only
Name of the Dealer/Repairer and phone number
The licensee whose professional opinion the form records.
Watch out: It has to be a business licensed by the State of Connecticut. A friend who is good with cars cannot complete one.
3
Dealers only
Address of the Dealer/Repairer
The licensee's address, on the line beneath the name.
Watch out: The department cross-references this against the licence number at the foot, which is why both boxes exist.
4
Dealers only
The condition ticks
Nine boxes, one or more of which has to be ticked to support the valuation. Rot, fire, stripping, missing tyres, broken glass, interior and steering column damage, and Other with an explanation.
Watch out: This is the part of the form worth reading before you sell a rough car. It is the department's own list of what makes a Connecticut vehicle worth less than $1,500.
5
Dealers only
Photographs
Not a box at all - an instruction in capitals across the sheet to include photographs of the damage described.
Watch out: Take your own photographs the same day. If the car moves or is stripped further before the file is looked at, yours are the only record of how it was.
6
Dealers only
Signature of Licensee and Dealer/Repairer License Number
The signature and the licence number, under the false statement certification.
Watch out: There is no owner signature line anywhere on this form. If somebody asks you to sign one, they have handed you the wrong document.
At a glance
What goes where
On the form
What to put in it
Vehicle Year, Vehicle Make, Vehicle Model, Vehicle Identification Number
Four boxes across the top row identifying the car.
Name of the Dealer/Repairer and Phone Number
The licensee making the statement.
Address of the Dealer/Repairer
Number and street, city or town, state and ZIP on the line beneath.
The opinion
As a Dealer or Repairer licensed by the State of Connecticut, it is in our professional opinion that the vehicle described above is valued at less than one thousand five hundred dollars ($1,500). This valuation reflects the observed condition of the vehicle, including any visible damage or missing major component part(s).
Extensive body and/or frame damage
The first of nine tick boxes. The reduced valuation is based on one or more of the following.
Vehicle stripped/missing body parts
The second.
Damaged by fire
The third.
Extensive interior damage
The fourth.
Steering column/ignition assembly damaged
The fifth.
Extensive body or frame rot
The sixth, and the one that describes most old New England cars that fail this way.
Tires missing
The seventh.
Broken windshield and/or windows
The eighth.
Other (Explain)
The ninth, with a free-text area beneath it.
INCLUDE PHOTOGRAPHS OF VEHICLE DAMAGE DESCRIBED ABOVE.
Printed across the sheet in capitals and underlined. Not optional.
Signature of Licensee, Dealer/Repairer License Number, Date Signed
Three boxes at the foot under the false statement certification.
What gets this one rejected
•An owner signing it. Every version of the certification on the sheet begins as a Dealer or Repairer licensed by the State of Connecticut.
•No licence number. It is the only thing on the form that proves the opinion is one the department accepts.
•No photographs. The requirement is printed across the sheet in capitals and underlined, which is unusual enough on a DMV form to mean it.
•No tick at all. The valuation has to be based on one or more of the listed conditions, and Other requires an explanation.
•A vehicle that is plainly worth more. The statement is made under penalty of false statement by a licensee whose licence is on the line.
Rules that decide whether it is accepted
•It is somebody else's professional opinion, obtained by you. The useful move for a seller is to ask a licensed repairer to look at the car and complete one, not to fill it in and take it to them.
•The threshold is fixed at $1,500. The number is printed in the certification in words and figures. There is no scale and no other figure the form can produce.
•Photographs travel with it. The capitalised instruction means the file the department receives is the form plus the pictures, not the form alone.
•It is a Dealers and Repairers Section form. The masthead says so, and that is a different unit from the Title Unit at Room 305 that handles certificates.
•Revised in June 2025. The most recently revised document in this state's seller-adjacent set, which is worth knowing if you have an older copy saved.
Every line here was read off H-116 (Rev 6-2025) itself — the PDF is here — and off the Connecticut Department of Motor Vehicles pages.
This is plain-language help with a form, not legal advice, and where our wording and the agency's differ,
theirs governs.
