Fillable SALVAGE CERTIFICATE APPLICATION (Virginia Department of Motor Vehicles)

Fill Online, Printable, Fillable, Blank SALVAGE CERTIFICATE APPLICATION (Virginia Department of Motor Vehicles) Form

Use Fill to complete blank online VIRGINIA DEPARTMENT OF MOTOR VEHICLES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

SALVAGE CERTIFICATE APPLICATION (Virginia Department of Motor Vehicles)

On average this form takes 24 minutes to complete

The SALVAGE CERTIFICATE APPLICATION (Virginia Department of Motor Vehicles) form is 2 pages long and contains:

  • 0 signatures
  • 59 check-boxes
  • 70 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Virginia Department of Motor Vehicles forms online.

BROWSE VIRGINIA DEPARTMENT OF MOTOR VEHICLES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
VSA 56 (07/01/2020)
SALVAGE CERTIFICATE APPLICATION
VEHICLE COLOR
Is there a lien on
this vehicle?
Check box and enter name of city, county or town where vehicle is principally garaged.
OWNER FULL LEGAL NAME (last) (first) (middle) (suffix)
SSN, FEIN OR VA DRIVER'S LICENSE NUMBER
OWNER STREET ADDRESS CITY ZIP CODE
CO-OWNER FULL LEGAL NAME (last) (suffix)(middle)(first)
SSN, FEIN OR VA DRIVER'S LICENSE NUMBER EMAIL ADDRESS
STATE
TELEPHONE NUMBER
DEALER/REBUILDER NUMBER
OWNER INFORMATION
LIEN INFORMATION
YES - Complete this section.
NO - Go to SOURCE INFORMATION section
LIEN DATE (mm/dd/yyyy) LIENHOLDER NAME
LIENHOLDER MAILING ADDRESS ZIP CODECITY
SOURCE INFORMATION
VEHICLE PURCHASED FROM SALE PRICE SALES AND USE TAX PURCHASE DATE (mm/dd/yyyy)
ZIP CODECITYSTREET ADDRESS
CURRENT TITLE ISSUE DATE (mm/dd/yyyy) CURRENT TITLE NUMBER
VEHICLE INFORMATION
CITY
COUNTY
VEHICLE IDENTIFICATION NUMBER
YEAR
MODEL BODY TYPE
EMPTY WEIGHT GROSS WEIGHT NUMBER OF AXLES FUEL TYPE
ACTUAL CASH VALUE (if required) ESTIMATED REPAIRS COST (if required) PERCENT OF DAMAGE (if required) VEHICLE ACQUIRED DATE (mm/dd/yyyy)
INSURANCE COMPANY NAME INSURANCE CODE NUMBER INSURANCE CLAIM NUMBER CLAIM PAYMENT DATE (mm/dd/yyyy)
DMV USE ONLY
SALE PRICE
REASON HELD
NCIC CHECK
WITH LIEN
TAX
TITLE FEE
TOTAL
SECONDARY
STATE
STATE
STATE
Purpose: Use this form to apply for a salvage certificate and/or to report water damage to a vehicle.
Instructions: Submit the completed application with the estimated cost of repairs to the Vehicle Branding Work Center at
the above address.
WATER DAMAGE CLAIM OF $3,500 OR MORE HAS BEEN PAID BY THE INSURANCE COMPANY
STOLEN VEHICLE
PRIMARY
To the best of my knowledge the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked:
ODOMETER READING
The mileage stated is in excess of its mechanical limits.
The odometer reading is not the actual mileage.
ODOMETER READING (no tenths) Federal and state law requires that you state the mileage in connection with the transfer of ownership. Failure to
complete the statement or providing a false statement may result in fines and/or imprisonment.
The model year is at least 10 years or older than the current calendar year and was
exempt from odometer disclosure in the prior state of title. (Applicant must present the
out-of-state title showing the exemption).
YES NO
TOWN of
MAKE
( )
VSA 56 (07/01/2020)
SALVAGE EXAM EXEMPTION
This section must be completed when applying for a rebuilt certificate of title without an examination. An examination is not required for applicants who
meet the following conditions:
• The person rebuilding the vehicle has been licensed under chapter (46.2-1605) for at least 10 years and has not had any penalties pursuant to
the provisions of this chapter
• The rebuilt vehicle is at least 10 years old but does not qualify as an antique motor vehicle
• The resale value is less than $10,000
All of the above conditions must be met in order to obtain a rebuilt title without an examination. Please complete the following for each license type you
currently possess.
Business Type License Number Established Date (mm/dd/yyyy)
Salvage Dealer
Rebulider
Demolisher
Auto Recycler
Scrap Metal Processor
Salvage Pool
Vehicle Removal Processor
Rebuilt Vehicle Resale Value:
ADDITIONAL INFORMATION
The information requested on an application for salvage certificate, in accordance with Virginia Code § 46.2-1603 (salvage certificate), as
amended, is subject to dissemination to authorized agencies or individuals. Any person who refuses to supply the required information
will be denied a salvage certificate. All salvage certificate records in the office of the Department of Motor Vehicles are privileged records
subject to such regulations as the Commissioner may adopt. Copies of administrative rules and regulations are available from the
Department of Motor Vehicles, Post Office Box 27412, Richmond, Virginia 23269-0001. This information is furnished to you in compliance
with Virginia Code § 2.2-3806.
All owners must sign. Giving misinformation with fraudulent intent is punishable as provided by law. Any person who falsely states the
selling price or evades payment of tax shall be guilty of a Class 3 misdemeanor.
I/We hereby make application for a Salvage Certificate for the vehicle described herein and I/we further 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.
CERTIFICATION
SIGNATURE OF APPLICANT
SIGNATURE OF APPLICANT
DATE (mm/dd/yyyy)
DATE (mm/dd/yyyy)
Page 2
PARTS REPAIRED/REPLACED (Required)
REPAIRED REPLACED REPAIRED REPLACED REPAIRED REPLACED REPAIRED REPLACED
Front Bumper Left Front Door Trunk Air Bags
Grill Right Front Door Rear Bumper Dash
Hood Left Rear Door Roof Dash Pad
Radiator Support Right Rear Door Engine
Left Fender Left Rear Quarter Panel Transmission
Right Fender Right Rear Quarter Panel Frame/Unibody
List other
damaged parts:
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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

SALVAGE CERTIFICATE APPLICATION (Virginia Department of Motor Vehicles)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document