Form Rv-F1315401 - Application For Motor Vehicle Identification Certification
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Tennessee Department of Revenue
Anti-Theft Unit Use Only
Special Investigations Section
Certification Number : _____________________
44 Vantage Way, Suite 160
Nashville, TN 37243-8050
Anti-Theft Decal Number: __________________
Application For
Required Brand: __________________________
Motor Vehicle Identification Certification
Applicant Information
Telephone Numbers
(please print clearly)
(include area code)
Name: __________________________________________________________
Home: ________________________________
Physical Address: _________________________________________________
Work: _________________________________
Mailing Address (if different): _______________________________________
Cell: _________________________________
City: _________________________________________, TN ______________
Vehicle Information
Year: ________ Make: ______________ Model: ______________ Identification Number: ___________________________________________
The damage to this vehicle was a result of:
_____ Collision _____ Fire ______ Fresh Water _____Salt Water _____ Theft _____ Other*
*If you marked other, explain the damage: ___________________________________________________________________________________
Vehicle Components
Listed below are the component parts that require proof of ownership. Identify those parts which were replaced on the subject vehicle during the
rebuilding process. For each part marked, submit a receipt showing the year, make and identification number of the vehicle from which the part was
removed. The receipt must also show the complete name and mailing address of the seller and buyer of the part. If the parts used were aftermarket or
new, it must be indicated on the receipt. Color photographs showing each quadrant of the vehicle in its damaged condition are also required.
_____ Frame
_____ Cowl
_____ Engine
_____ Transmission
_____ No Parts Used
_____ Front End Assembly
_____ Rear Clip
_____ Hood
_____ Roof Panel
_____ Deck Lid/Hatchback
_____ Interior
_____ Front Bumper
_____ Rear Bumper
_____ Right Rear Fender
_____ Left Rear Fender
_____ Right Front Fender
_____ Left Front Fender
_____ Right Front Door
_____ Left Front Door
_____ Right Rear Door
_____ Left Rear Door
_____ Driver Side Air Bag
_____ Passenger Side Air Bag _____ Left Rear Air Bag
_____ Right Rear Air Bag
_____ Cab
_____ Cab Clip
_____ Bed
_____ Tailgate
NOTE: Your signature on this form affirms that this vehicle was repaired in accordance with manufacturer’s safety specifications and
no stolen parts were used in the rebuilding process. Your signature also affirms that during the rebuilding process that all safety
requirements as outlined by the National Highway Traffic Safety Administration (NHTSA) have been met.
Tennessee Drivers License Number: _______________________________________________________________________________________
Federal Employer ID Number &/or Sales Tax Number: _______________________________________________________________________
Rebuilder: ____________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________________
Telephone Number (Home): ______________________________________ (Business): _____________________________________________
Signature of Rebuilder: _________________________________________________________________________________________________
STATE OF TENNESSEE, COUNTY OF ___________________________________________
Sworn to and subscribed before me this _______________________________ day of ___________________________________________________ 20______
_________________________________________________________
Notary Public (Seal)
My commission expires: ________________________________________________
RV-F1315401 (revised 07/08)
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Parent category: Financial