VSA 153 (01/25/2016)
VEHICLE SERVICES
PAYMENT AUTHORIZATION
Purpose: Customers fax this form to DMV for payment authorization.
Instructions: Do not mail this form. Fax the completed form to the applicable fax number listed in the Transaction/Fax
Information section.
APPLICANT INFORMATION
NAME DMV CUSTOMER NUMBER DAYTIME TELEPHONE NUMBER
MAILING ADDRESS CITY STATE ZIP CODE
VEHICLE INFORMATION
Plate Number VIN Make Year Title Number State of Title
I authorize DMV to charge the credit card account listed.
CARD HOLDER SIGNATURE
DATE (mm/dd/yyyy)
PAYMENT AUTHORIZATION
CREDIT CARD (check one)
VISAMASTERCARD
NAME APPEARING ON CREDIT CARD DAYTIME TELEPHONE NUMBER
AMOUNT TO BE CHARGED
$
AMERICAN
EXPRESS
DISCOVER
CREDIT CARD NUMBER EXPIRATION DATE (mm/yy)
TRANSACTION/FAX INFORMATION
Identify the applicable Work Center for the transaction you are completing and fax this completed form to the number provided.
Vehicle Branding Work Center
Fax Number: (804) 367-2723
Titling Work Center
Fax Number: (804) 367-6679
Special Registration
Fax Number: (804) 367-6379
Dealer Services Work Center
Fax Number: (804) 367-7046
Vehicle Salvage Exam Original Title Clean Fuel Plate (include VSA 10) Manufacturer Licensing and Plates
Branded Out-of-State Title Supplemental Title Disabled Veteran Plate Drive-Away Plates
Salvage Certificate Replacement/Substitute Title Transfer Plate Office Trailer Plates
VIN Inspection VSA 12 Renewal of Overload Permit
VSA 12 (Salvage) Original Overload Permit
Mechanics or Storage Lien
DEALER INFORMATION
APPLICATION TYPE
COMMENTS
