CRD 1 (02/10/2015)
Purpose: Use this form to request vehicle history information on a vehicle being considered for purchase. Requesting this
information is authorized under section 46.2-209.1 of the Code of Virginia.
Instructions: Print clearly or type. All information must be provided except Post Office Box and Business/Organizational Affiliation
which are optional. An FEIN or social security number is required by the State Comptroller for debt set-off collection in
accordance with Virginia Code SS 2.1-196, 2.1-731, 2.1-734 et..al. Submit completed form and $12.00 payment in
person at any DMV Customer Service Center or mail to the address above.
NOTE: When mailing this request, DMV can only accept checks or money orders.
REQUEST FOR VEHICLE INFORMATION
BY A PROSPECTIVE PURCHASER
REQUESTER NAME (print) (last) (first) (middle) (suffix)
REQUESTER INFORMATION
BUSINESS/ORGANIZATIONAL AFFILIATION (Optional)FEIN/SOCIAL SECURITY NUMBER
VEHICLE INFORMATION
VEHICLE IDENTIFICATION NUMBER MODEL YEARVEHICLE MODEL VEHICLE MAKE
CITY/TOWN/VILLAGE ZIP/POSTAL CODESTATE/PROVINCE COUNTRYPOST OFFICE BOX
STREET ADDRESS
TELEPHONE NUMBER
I certify that I am considering purchasing the vehicle described above. I understand that any information provided in response to this
request will be information that is available from the records of Virginia's DMV; that there may be other information about the vehicle that
may not be released by DMV or that exists in other states, countries or elsewhere and is not available to Virginia's DMV. I also
understand that Virginia DMV assumes no responsibility for errors or omission in the information provided in response to this request and
that fees are non-refundable. In the event that no record for this vehicle is found, a "no record" response will be provided.
I further understand that it is unlawful to use any information provided by DMV in response to this request for any other reason and I
agree that I will not copy, distribute or sell this information.
I also certify and affirm that all information presented on this form is true and correct, that any documents I have presented to DMV are
genuine and that the information included on 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 on this form is a criminal violation.
REQUESTER SIGNATURE
CERTIFICATION
DATE (mm/dd/yyyy)
DMV USE ONLY
FEE
CSR STAMP
PAYMENT METHODS
ENTER CHECK AMOUNT
CHECK
Made payable to DMV
MONEY ORDER
Made payable to DMV
ENTER MONEY ORDER AMOUNT
If you are mailing this request, DMV can only accept check or money order via mail.
