LES 022A (07/01/2018)
REQUEST FOR EXAMINATION
OF REBUILT SALVAGE VEHICLE
Purpose: Use this form to request an examination of a rebuilt salvage vehicle.
Instructions: Complete this form and return it to DMV at the above address along with the required documents and fees. If you have questions about
requesting an examination contact DMVDirect at (804) 497-7100 or visit us on the web at www.dmvnow.com.
NOTE: You must be licensed as a rebuilder to have two or more salvage vehicles examined within a 12 month consecutive period.
PARTS REPAIRED/REPLACED (must be completed)
REPAIRED REPLACED REPAIRED REPLACED REPAIRED REPLACED REPAIRED REPLACED
Front Bumper Right Fender Left Rear Quarter Panel Engine
Grill Left Front Door Right Rear Quarter Panel Transmission
Hood Right Front Door Trunk Frame/Unibody
Radiator Support Left Rear Door Rear Bumper Air Bags
Left Fender Right Rear Door Roof Dash
Water Damaged
or Not Listed:
SPECIFY REPAIRS
If you have replaced a Pickup Cab or Frame, vehicle is reconstructed and may need to be assigned a new Vehicle Identification Number.
DOCUMENTS & FEES REQUIRED FOR PROCESSING
Virginia Salvage Title In Your Name - Completed LES 022A - VA Salvage Title - Title Fee $15 - Exam Fee $125
Virginia Salvage Title Assigned To You -
Completed LES 022A - VA Salvage Title - Salvage Certificate Application (VSA56) - Bill of Sale -
4.15% Sales Tax or minimum $75 whichever is greater - Title Fee $15 - Exam Fee $125
Out-of-State Salvage Title In Your Name (or)
Out-of-State Salvage Title Assigned To You -
Completed LES 022A - Out-of-State Title - Salvage Certificate Application (VSA56) - Bill of Sale (if title is not in
your name) - 4.15% Sales Tax or minimum $75 whichever is greater - Proof of Sales Tax paid in another state
(if paid) - Title Fee $15 - Exam Fee $125
CERTIFICATION (all owners must sign)
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.
OWNER/AUTHORIZED AGENT NAME (print)
OWNER/AUTHORIZED AGENT SIGNATURE
DATE (mm/dd/yyyy)
OWNER/AUTHORIZED AGENT NAME (print)
OWNER/AUTHORIZED AGENT SIGNATURE
DATE (mm/dd/yyyy)
REQUIREMENTS FOR VEHICLE EXAMINATION
Vehicle MUST be rebuilt prior to submitting this request - painting is optional. If vehicle does not pass the examination or you fail to keep your scheduled
appointment you must request a new examination, submit a new LES 022A and pay the necessary fees.
Vehicle must have passed a VA State safety
inspection after completion of the repairs and
prior to the exam. VA Code § 46.2-1605.
You may obtain a trip permit to move your vehicle to and
from a VA state safety inspection facility using the below
link. www.dmv.virginia.gov/vehicles/temp_permit.asp.
Initial here that the state safety inspection is
complete.
Other items required for the exam - Original part receipts - Photo of the vehicle prior to repairs - Old component parts containing a VIN (if available).
REQUESTERS INFORMATION
INDIVIDUAL/COMPANY NAME (print - last, first, middle, suffix) DRIVER LICENSE NUMBER/FEIN
STREET ADDRESS (no P.O. Box) CITY STATE ZIP CODE
VEHICLE LOCATION ADDRESS (if different from above) CITY STATE ZIP CODE
BEST TIME TO CONTACT YOU TELEPHONE NUMBER CELL PHONE NUMBER EMAIL ADDRESS
REBUILDER LICENSE NUMBER LICENSE EXPIRATION DATE NMVTIS ID NUMBER INDEPENDENT DEALER NUMBER LICENSE EXPIRATION DATE
If you were not involved in the actual repairing of the vehicle, enter the Individual/Company name and address who repaired the vehicle.
INDIVIDUAL/COMPANY NAME (print - last, first, middle, suffix)
STREET ADDRESS (no P.O. Box) CITY STATE ZIP CODE
VEHICLE INFORMATION
YEAR MAKE MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER (VIN) # AXLES COLOR
