Form Nsp455 - Motor Vehicle Identification Certificate Void After 90 Days
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2NEBRASKA STATE PATROL
MOTOR VEHICLE IDENTIFICATION CERTIFICATE
VOID AFTER 90 DAYS
Section 1: TO BE COMPLETED BY STATE LAW ENFORCEMENT OFFICER ONLY
Vehicle Identification Number (VIN)
State of Current Title ______________________ Title Number ________________________
Model Year _____________ Make __________________ Model _______________________
Does the VIN appear to have been altered or tampered with?
Yes
No
Does the VIN agree with the supporting documents?
Yes
No
Does the Federal Label agree with the Public VIN?
Yes
No
Does the Federal Label agree with the supporting documents?
Yes
No
Odometer Reading ______________________
Date of NCIC Check __________________
Remarks ______________________________________________________________________
This is to certify that I have made a physical examination of the above vehicle and its documents.
I am an officer of a
employed by the
of
_______________.
STATE POLICE AGENCY
STATE
Date_________ Name (please print)_____________________________________________
Badge No _________Title/Rank _________________________________________________
State Agency ___________________________________Work Phone ___________________
Signature __________________________________________________________
Section 2: TO BE COMPLETED BY APPLICANT
Effective August 31, 2003 there is a $10.00 processing fee.
Please include a check or money order made payable to the Nebraska State Patrol.
RETURN APPROVED CERTIFICATE TO:
Name ______________________________________ Phone ____________________________
Address ______________________________________________________________________
City ___________________________________ State _____________________ Zip _________
th
Section 3: Forward completed certificate to Nebraska State Patrol, Auto Fraud Division, 3800 NW 12
St., Lincoln, Ne., 68521. Certificate will be approved by the Nebraska State Patrol and returned to the
address specified in section 2.
NEBRASKA STATE PATROL APPROVAL:
NAME: ___________________________________
DATE:__________________
TITLE: ___________________________________
NSP455 (05/09)
VOID AFTER 90 DAYS
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