VSA 140 (07/01/2017)
ACKNOWLEDGEMENT
NONNEGOTIABLE JUNK TITLE
NOT FOR RESALE
Purpose: Customers can use this form to apply for a nonnegotiable junk title with registration. The vehicle MUST have
an out of state brand that is equivalent to Virginia’s nonrepairable requirements, provided the vehicle has
been rebuilt/repaired, titled, and registered in another state.
Instructions: Submit the completed form, required documentation, and applicable fees to the Vehicle Branding Work
Center at the address above.
OWNER INFORMATION
OWNER'S FULL LEGAL NAME (last, first, mi, suffix) OR BUSINESS NAME (if business owned) TELEPHONE NUMBER DMV CUSTOMER NUMBER / FEIN / SSN
CO-OWNER'S FULL LEGAL NAME (last, first, mi, suffix) TELEPHONE NUMBER DMV CUSTOMER NUMBER / FEIN / SSN
CUSTOMER MAILING ADDRESS CITY STATE ZIP CODE
CUSTOMER STREET ADDRESS (if different) CITY STATE ZIP CODE
EMAIL ADDRESS
VEHICLE INFORMATION
VEHICLE YEAR VEHICLE MAKE VEHICLE MODEL VEHICLE BODY TYPE
VIN STATE OUT OF STATE TITLE NUMBER
ACKNOWLEDGEMENT (Read Carefully)
Virginia Code § 46.2-1606 requires a vehicle to have been rebuilt/repaired, titled, and registered in another state in order to be eligible for a
nonnegotiable title. In addition, a vehicle that has been declared to be nonrepairable in Virginia cannot receive a nonnegotiable title,
regardless of whether or where it has been rebuilt/repaired. By signing this form, you acknowledge the following as conditions on the
issuance of a nonnegotiable title for this vehicle:
1. I understand I cannot transfer ownership except as provided in VA Code §§ 46.2-633, 46.2-633.2, and 46.2-634 or to an insurance
company as part of the claims process;
2. I am not titling this vehicle for the purpose of resale;
3. I intend to drive this vehicle; and
4. I understand I cannot add a co-owner after the nonnegotiable title has been issued.
ATTACHED DOCUMENTATION (Required)
Proof vehicle has been repaired (Documentation from the seller) VSA 17A - Application for Certificate of Title and Registration
Proof vehicle has been title and registered out of state (Title and registration card)
CERTIFICATION/SIGNATURES
I/We certify and affirm that all information presented in this form is true and correct, that any documents I/we have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I/We make this certification and affirmation under penalty of perjury and I/we understand
that knowingly making a false statement or representation on this form is a criminal violation.
APPLICANT PRINTED NAME
APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
CO-APPLICANT PRINTED NAME
CO-APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
