VSA 22 (07/01/2018)
APPLICATION FOR ASSIGNED
VEHICLE IDENTIFICATION NUMBER
Purpose: Use this form to apply for an assigned vehicle identification
number.
Instructions: Return the completed form to DMV at the above address.
DMV USE ONLY
VIN PLATE ASSIGNED
VEHICLE INFORMATION
COMPLETE ONLY FOR HOMEMADE TRAILER
TRAILER TYPE (check one)
BOAT TRAILER UTILITY TRAILER CAMPING TRAILER HORSE TRAILER
OTHER (specify)
If you were not involved in the actual construction of this trailer, enter the builder's name and address below.
BUILDER NAME
STREET ADDRESS CITY STATE
ZIP CODE
CERTIFICATION OF INSTALLED VEHICLE IDENTIFICATION NUMBER
This certification must be signed by a Virginia Law Enforcement Officer and returned to DMV with an Application for Title and Registration (VSA- 17A) before
a title and license plate(s) can be issued.
NOTE: For a reconstructed vehicle, specially constructed vehicle, replica motor vehicle or a vehicle missing the Vehicle Identification Number (VIN); a DMV
special agent must install the assigned VIN plate and certify its installation below.
I certify that the assigned Vehicle Identification Number has been attached to the vehicle described below.
SIGNATURE DATE (mm/dd/yyyy)
BADGE NUMBER
AGENCY
REASON FOR APPLICATION
Check one. Please note document and fees required.
SPECIALLY CONSTRUCTED VEHICLE - Original title, bills of sale,
certificate of origin, and notarized statement of construction; photo of
vehicle; and $145.00 fee. ($5.00 VIN application, $125.00 examination fee
and $15.00 title fee.)
VIN VERIFICATION (Check appropriate type)
Original title in your name and $145.00 fee. ($5.00 VIN application,
$125.00 examination fee, and $15.00 title fee.)
MISSING
ALTEREDCHANGED
RECONSTRUCTED VEHICLE - Same as above.
HOMEMADE TRAILER - (Complete the Homemade Trailer
Information Section) ($5.00 fee.)
REPLICA VEHICLE - Same as above.
MAKE BODY TYPE NUMBER OF AXLES YEAR OR CONSTRUCTION DATE (mm/dd/yyyy)
CURRENT VEHICLE IDENTIFICATION NUMBER (VIN, if any)
OWNER INFORMATION
OWNER NAME (last, first, mi, suffix) CUSTOMER NUMBER/FEIN/SSN PRIMARY TELEPHONE NUMBER
STREET ADDRESS
CITY STATE ZIP CODE
ALTERNATE TELEPHONE NUMBER
CO-OWNER NAME (last, first, mi, suffix) CUSTOMER NUMBER/FEIN/SSN PRIMARY TELEPHONE NUMBER
CO-OWNER STREET ADDRESS
CITY STATE ZIP CODE
ALTERNATE TELEPHONE NUMBER
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)
