VSA 122 (11/10/2017)
As required by Virginia Code § 46.2-1207, I certify that (check one):
AUTHORIZED OFFICIAL'S NAME (print) LOCALITY NAME (city, county or town)
AUTHORIZED OFFICIAL'S TITLE
DEMOLISHER NUMBERAUTHORIZED DEMOLISHER NAME (print)
4. LOCALITY INFORMATION AND CERTIFICATION (CITY, COUNTY OR TOWN)
SIGNATURE
DATE (mm/dd/yyyy)
The vehicle described above is inoperable and abandoned, was left on property within the locality identified herein, and has been disposed of as
provided in Virginia Code § 46.2-1205.
The vehicle described above is inoperable, has been removed from the above identified vehicle owner's property, and disposed of by the locality,
or its authorized agent, identified herein.
I also certify that possession of the inoperable vehicle was transferred to the registered demolisher identified on page 2. I further certify and affirm that
all information presented in this section is true and correct, that any documents I have presented to DMV are genuine, and that the information included
in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly
making a false statement or representation on this form is a criminal violation.
ADDRESS CITY ZIP CODE
3. TOWING INFORMATION AND CERTIFICATION
I certify and affirm that I obtained approval at the time the vehicle was towed in accordance with Virginia Code § 46.2-1232. I further certify and affirm
that all information presented in this section is true and correct, that any documents I have presented to DMV are genuine, and that the information
included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that
knowingly making a false statement or representation on this form is a criminal violation.
TOWING COMPANY REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
LICENSED VEHICLE REMOVER'S COMPANY NAME
The vehicle described
above was released to
VRO CERTIFICATE NUMBER (or tow truck plate number)
→
STATE
VA
OPERATOR NAME (print)
TOWING COMPANY REPRESENTATIVE NAME (print) (if different than operator)
I certify and affirm that all information presented in this section is true and correct, that any documents I have presented to DMV are genuine, and that
the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I
understand that knowingly making a false statement or representation on this form is a criminal violation.
PROPERTY OWNER/AUTHORIZED AGENT SIGNATURE
DATE (mm/dd/yyyy)
PROPERTY OWNER/AUTHORIZED AGENT NAME (print)
2. PROPERTY OWNER/AUTHORIZED AGENT INFORMATION AND CERTIFICATION
Complete this section ONLY if vehicle location listed above is private property.
CHECK ONE:
1. VEHICLE INFORMATION
VEHICLE LOCATION (street address or nearest intersection, landmark, etc.) CITY ZIP CODE
VEHICLE YEAR VEHICLE MAKE VEHICLE MODEL VEHICLE IDENTIFICATION NUMBER (VIN)
VEHICLE TYPE
AUTO
TRUCK
TRAILERMOTORCYCLE OTHER ___________________________________
STATE
VA
INOPERABLE VEHICLE WAS REMOVED FROM THE VEHICLE OWNER'S PROPERTY WITHIN THE LOCALITY.
INOPERABLE VEHICLE WAS ABANDONED AND REMOVED FROM PUBLIC OR PRIVATE PROPERTY WITHIN THE LOCALITY.
DMV HQ USE ONLY
Is the vehicle identification number (VIN) on the customer service system (CSS)?
YES NO
Is the vehicle currently registered? Is the vehicle recorded as stolen?
YES NO YES NO
Has the vehicle been previously entered as demolished?
YES NO
Purpose: Local governments use this form to track and certify the disposition of, and request reimbursement for, the disposition of inoperable
vehicles located within the locality (Virginia Code § 46.2-1207). All other vehicle dispositions are reported using the Vehicle Removal
Certificate (VSA 40).
Instructions: Submit this form to DMV to certify and report the removal and disposition of an inoperable motor vehicle either from the vehicle owner's
property, or from property within the locality where it was abandoned, and to request reimbursement for such vehicle as provided in
Virginia Code § 46.2-1207. Follow full instructions on the back of this form.
LOCAL GOVERNMENT REIMBURSEMENT
FOR INOPERABLE VEHICLE DISPOSITION
TELEPHONE NUMBER
TELEPHONE NUMBER
