Fillable Vsa40 VEHICLE REMOVAL CERTIFICATE (Virginia Department of Motor Vehicles)

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Vsa40 VEHICLE REMOVAL CERTIFICATE (Virginia Department of Motor Vehicles)

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VSA 40 (11/10/2017)
PURCHASER NAME (print)
4. SALE OF ABANDONED VEHICLE (AVP) INFORMATION
The vehicle described
above was sold to
I certify and affirm that I have complied with all requirements of the Virginia Motor Vehicle law for the above abandoned vehicle, trailer or manufactured home and am eligible
to transfer ownership to a third party. I further certify and affirm that all information presented in this section is true and correct, that any documents I have presented to DMV
are genuine, and that the information included in 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 or representation on this form is a criminal violation.
SELLER SIGNATURE
DATE (mm/dd/yyyy)
→
PURCHASE DATE (mm/dd/yyyy)PURCHASE PRICE
3. VEHICLE DISPOSITION
I certify and affirm that I have complied with all requirements of the Virginia Motor Vehicle law for the above vehicle, trailer, or manufactured home and am:
I further certify and affirm that all information presented in this section is true and correct, that any documents I have presented to DMV are genuine, and that the information
included in 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 or representation on this form is a criminal violation.
obtaining title in my name (signature required below),
selling at auction (complete section 4),
transferring to a demolisher or scrap metal processor.
(complete section 5)
DATE (mm/dd/yyyy)
SIGNATURE OF PERSON/AUTHORIZED AGENT IN POSSESSION OF VEHICLE
LICENSED VEHICLE REMOVER'S COMPANY NAME
OPERATOR NAME (print)
ADDRESS CITY STATE ZIP CODE
2. TOWING COMPANY INFORMATION AND CERTIFICATION
The vehicle described
above was released to
VRO CERTIFICATE NUMBER (or tow truck plate number)
TOWING COMPANY REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
→
TOWING COMPANY REPRESENTATIVE NAME (print) (if different than operator)
DATE (mm/dd/yyyy)
ONLINE AVP RECEIPT NUMBER (if applicable)
I certify and affirm that all information presented in this section is true and correct, that any documents I have presented to DMV are genuine, and that the information
included in 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 or representation on this form is a criminal violation.
SIGNATURE OF PERSON/AUTHORIZED AGENT IN POSSESSION OF VEHICLE
I certify and affirm that all information presented in this section is true and correct, that any documents I have presented to DMV are genuine, and that the information
included in 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 or representation on this form is a criminal violation.
ADDRESS CITY ZIP CODESTATE
1. VEHICLE/TRAILER/MANUFACTURED HOME INFORMATION
VEHICLE LOCATION CITY ZIP CODE
VEHICLE YEAR VEHICLE MAKE VEHICLE MODEL VEHICLE IDENTIFICATION NUMBER (VIN)
VEHICLE TYPE
AUTO
TRUCK
TRAILERMOTORCYCLE OTHER _________________
FULL NAME OF PERSON/AUTHORIZED AGENT IN POSSESSION OF VEHICLE
MANUFACTURED HOME
Purpose: This form is used by any person (individual, business, government; see VA Code §1-230) or their authorized agent(s) to track and record
the removal and/or disposition of a motor vehicle, trailer or manufactured home in their possession.
Instructions: Complete and submit this form following the instructions on the back of the form.
DMV HQ USE ONLY
Is the vehicle identification number (VIN) on the customer service system (CSS)? Is the vehicle currently registered?
YES NO
YES NO
If VIN is not on CSS, is Abandoned Vehicle Receipt attached? Has the vehicle been previously entered as demolished?
YES NO
YES NO
Is the vehicle recorded as stolen?
YES NO
VEHICLE REMOVAL CERTIFICATE
STATE
VA
ADDRESS OF PERSON/AUTHORIZED AGENT IN POSSESSION OF VEHICLE CITY ZIP CODESTATE
TELEPHONE NUMBER
( )
VSA 40 (11/10/2017)
INSTRUCTIONS
Section 1: The person or authorized agent in possession of the vehicle, trailer or manufactured home completes the vehicle and
applicant information, and signs.
Section 2: The licensed vehicle remover completes and signs this section if the vehicle is towed. DMV must receive the original VSA
40 form.
Section 3: The person or authorized agent in possession of the vehicle, trailer or manufactured home must indicate his or her intent to
title, sell or transfer the vehicle, trailer or manufactured home for demolition.
Section 4: The person or authorized agent in possession of a vehicle, trailer, or manufactured home that has been processed using
DMV's online Abandoned Vehicle Process (AVP), completes this section and provides the purchaser with the AVP receipt
and the completed, signed VSA 40 for use in titling the vehicle unless transferred directly to a licensed demolisher (See
Section 5).
Section 5: The person or authorized agent transferring possession of the vehicle, trailer or manufactured home to a licensed
demolisher or scrap metal processor signs this section and transfers this form with the vehicle to the demolisher/scrap
metal processor. The licensed demolisher or scrap metal processor completes this section to certify that the vehicle, trailer
or manufactured home was demolished or scrapped. A license number, signature, date and telephone number are
required.
Manual Reporting of Vehicle Disposition to DMV:
Licensed demolishers or scrap metal processors, who do not report vehicle disposition electronically per Va. Code
§46.2-1608.2, return the original VSA 40 form and applicable documents as required to DMV at the following address:
Virginia Department of Motor Vehicles
Data Integrity Room 516
Post Office Box 27412
Richmond, Virginia 23269-0001
NOTE: A copy of this VSA 40 form must be retained by the demolisher/scrap metal processor in accordance with the
requirements in VA Code §46.2-1206.
Electronic Reporting of Vehicle Disposition to DMV:
Licensed demolishers or scrap metal processors who report vehicle disposition electronically to DMV per Va. Code
§46.2-1608.2 shall retain the original VSA 40 form, proof of ownership document(s) and applicable DMV forms (as
required), on file in a secure location for at least five years in accordance with the requirements in Va. Code §46.2-1206.
These files are subject to inspection by law-enforcement.
COMMENTS (Use the area below to enter any additional information.)
Page 2
CHECK ONE OF THE FOLLOWING OR STAMP THE BLANK SPACE BELOW WITH APPROVED MERCURY SWITCH STAMP:
DEMOLISHER/SCRAP METAL PROCESSOR COMPANY NAME (Transferee)
DEMOLISHER CERTIFICATE NUMBER
The mercury switches have been removed from the vehicle, were previously removed from the vehicle, or the vehicle was not manufactured with
mercury switches.
The mercury switches could not be removed from the vehicle because upon attempt it was determined removal of the switches would be
impractical, unreasonable or unsafe.
I certify that the vehicle has been demolished/scrapped. I further certify and affirm that all information presented in this section is true and correct, that
any documents I have presented to DMV are genuine, and that the information included in 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 or representation on this form is a
criminal violation.
DATE DEMOLISHED OR SCRAPPED (mm/dd/yyyy)
DEMOLISHER/SCRAP METAL PROCESSOR REPRESENTATIVE SIGNATURE
5. DEMOLISHER/SCRAP METAL PROCESSOR INFORMATION AND CERTIFICATION
As provided under VA Code, I have transferred possession of the above described vehicle to the licensed demolisher or scrap metal processor listed below for the purpose
of demolition or conversion to scrap.
VEHICLE TRANSFER DATE (mm/dd/yyyy)
INDIVIDUAL/AUTHORIZED AGENT SIGNATURE (Transferor)
TELEPHONE NUMBER
( )
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Vsa40 VEHICLE REMOVAL CERTIFICATE (Virginia Department of Motor Vehicles)

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Completed 29 July 2020

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