VSA 57 (07/01/2017)
I hereby certify and acknowledge that the vehicle described above is damaged to such an extent that it is nonrepairable, and by so certifying, I
understand that in accordance with Virginia Code § 46.2-1603.2 and § 46.2-1605, that the vehicle for which a nonrepairable certificate is issued SHALL
NEVER BE TITLED OR REGISTERED FOR USE ON THE HIGHWAYS AND SUCH VEHICLE MAY ONLY BE USED FOR PARTS.
I further certify and affirm that all information presented in this form 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.
CERTIFICATION
OWNER OR CORPORATE OFFICER AUTHORIZED INDIVIDUAL NAME (print) TITLE
OWNER OR CORPORATE OFFICER AUTHORIZED INDIVIDUAL SIGNATURE
DATE (mm/dd/yyyy)
CO-OWNER NAME (if applicable) (print)
CO-OWNER SIGANTURE (if applicable) (print)
DATE (mm/dd/yyyy)
NONREPAIRABLE CERTIFICATE APPLICATION
Purpose: Customers use this form to apply for a no-fee nonrepairable certificate. Any vehicle that has been determined by its
insurer or owner, to have no value except for use as parts and scrap metal or for which a nonrepairable certificate has
been issued or applied for.
Instructions: Return the completed form with the vehicle title and/or other authorized documents to the Vehicle Branding Work
Center at the above address.
LOG NUMBER _______________________________________________________ TITLE NUMBER ____________________________________________________
VEHICLE INFORMATION
VEHICLE IDENTIFICATION NUMBER (VIN) YEAR MAKE BODY TYPE TITLE NUMBER
INDIVIDUAL OWNER INFORMATION (if applicable)
OWNER FULL LEGAL NAME (last) (first) (mi) (suffix)
CO-OWNER FULL LEGAL NAME (last) (first) (mi) (suffix)
ADDRESS CITY STATE ZIP CODE
TELEPHONE NUMBER OWNER SSN OR VA DRIVER LICENSE NUMBER CO-OWNER SSN OR VA DRIVER LICENSE NUMBER
INSURANCE COMPANY INFORMATION (if applicable)
INSURANCE COMPANY NAME
TELEPHONE NUMBER FEDERAL ID NUMBER
INSURANCE COMPANY CODE NUMBER INSURANCE COMPANY CLAIM NUMBER CLAIM PAYMENT DATE (mm/dd/yyyy)
ADDRESS CITY STATE ZIP CODE
