Fillable (DO NOT WRITE, MARK, OR STAMP ABOVE THIS (Tennessee County Clerk)

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(DO NOT WRITE, MARK, OR STAMP ABOVE THIS (Tennessee County Clerk)

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(DO NOT WRITE, MARK, OR STAMP ABOVE THIS LINE)
TENNESSEE DEPARTMENT OF REVENUE
SPECIAL INVESTIGATIONS SECTION
44 VANTAGE WAY, SUITE 160
NASHVILLE, TN 37243-8050
APPLICATION FOR
TENNESSEE SALVAGE CERTIFICATE
TENNESSEE NON-REPAIRABLE CERTIFICATE
DATE
INVOICE NO.
TRANSACTION
TYPE
DATE
VEHICLE PURCHASED
CERTIFICATE NUMBER
VIN
LAST NAME
FIRST NAME
MIDDLE INITIAL
MAKE
YEAR
BUSINESS NAME OR CO-OWNER NAME
MODEL
BODY TP
STREET ADDRESS
CITY
STATE
ZIP CODE
CURRENT TITLE NO.
STATE
POLICY NUMBER
ODOMETER READING
WRITTEN SIGNATURE OF OWNER
DATE
WRITTEN SIGNATURE (By Power of Attorney)
DATE
FORM MUST BE PRINTED OR TYPEWRITTEN IN BLACK
RV-F1311801 (Rev. 4-12)
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(DO NOT WRITE, MARK, OR STAMP ABOVE THIS (Tennessee County Clerk)

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Completed 2 June 2021

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