Application For
Motor Vehicle Identification Certification
Applicant Information (please print clearly) Telephone Numbers (include area code)
Name: __________________________________________________________ Home: ________________________________
Physical Address: _________________________________________________ Work: _________________________________
Mailing Address (if different): _______________________________________ Cell: _________________________________
City: _________________________________________, TN ______________
Vehicle Information
Year: ________ Make: ______________ Model: ______________ Identification Number: ___________________________________________
The damage to this vehicle was a result of: _____ Collision _____ Fire ______ Fresh Water _____Salt Water _____ Theft _____ Other*
*If you marked other, explain the damage: ___________________________________________________________________________________
Vehicle Components
Listed below are the component parts that require proof of ownership. Identify those parts which were replaced on the subject vehicle during the
rebuilding process. For each part marked, submit a receipt showing the year, make and identification number of the vehicle from which the part was
removed. The receipt must also show the complete name and mailing address of the seller and buyer of the part. If the parts used were aftermarket or
new, it must be indicated on the receipt. Color photographs showing each quadrant of the vehicle in its damaged condition are also required.
_____ Frame _____ Cowl _____ Engine _____ Transmission _____ No Parts Used
_____ Front End Assembly _____ Rear Clip _____ Hood _____ Roof Panel
_____ Deck Lid/Hatchback _____ Interior _____ Front Bumper _____ Rear Bumper
_____ Right Rear Fender _____ Left Rear Fender _____ Right Front Fender _____ Left Front Fender
_____ Right Front Door _____ Left Front Door _____ Right Rear Door _____ Left Rear Door
_____ Driver Side Air Bag _____ Passenger Side Air Bag _____ Left Rear Air Bag _____ Right Rear Air Bag
_____ Cab _____ Cab Clip _____ Bed _____ Tailgate
NOTE: Your signature on this form affirms that this vehicle was repaired in accordance with manufacturer’s safety specifications and
no stolen parts were used in the rebuilding process. Your signature also affirms that during the rebuilding process that all safety
requirements as outlined by the National Highway Traffic Safety Administration (NHTSA) have been met.
Tennessee Drivers License Number: _______________________________________________________________________________________
Federal Employer ID Number &/or Sales Tax Number: _______________________________________________________________________
Rebuilder: ____________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________________
Telephone Number (Home): ______________________________________ (Business): _____________________________________________
Signature of Rebuilder: _________________________________________________________________________________________________
STATE OF TENNESSEE, COUNTY OF ___________________________________________
Sworn to and subscribed before me this _______________________________ day of ___________________________________________________ 20______
_________________________________________________________
Notary Public (Seal)
My commission expires: ________________________________________________
RV-F1315401 (revised 07/08)
Tennessee Department of Revenue
Special Investigations Section
44 Vantage Way, Suite 160
Nashville, TN 37243-8050
Anti-Theft Unit Use Only
Certification Number : _____________________
Anti-Theft Decal Number: __________________
Required Brand: __________________________
