Form 78-031 - Certification To Cancel Title For Scrapped, Dismantled Or Destroyed Vehicles

CERTIFICATION TO CANCEL TITLE

FOR SCRAPPED, DISMANTLED OR

DESTROYED VEHICLES

Form 78-031

THIS FORM MUST BE TYPED OR COMPUTER PRINTED AND CAN ONLY BE USED TO TRANSFER A

VEHICLE FOR PARTS OR SCRAP TO A LICENSED, USED MOTOR VEHICLE PARTS DEALER OR SCRAP

METAL PROCESSOR.

I, the undersigned, certify that I am the owner of the below described vehicle and one of the following applies:

1.) I never obtained a title to the vehicle in my name, or

2.) I was issued a title for the above described vehicle, but the title has been lost or stolen, or

3.) I have surrendered the title to MS Department of Revenue for cancellation per Miss. Code Ann. Section 63-21-39

(1).

I, the undersigned, further certify that the below described vehicle is at least ten (10) model years old and is not subject to any

secured interest or lien and the vehicle shall never be titled again; it must be dismantled or scrapped. Falsification of this form

and any information provided would result in a misdemeanor and/or felony per Miss. Code Ann. Section 63-21-39 (1)(J)(i) and

(ii).

VIN Number:

Make:________________________________ Model:____________________________ Year: _______________________

Seller’s Name:______________________________________________ Driver’s License Number: _____________________

Street Address:________________________________________________________________________________________

City:_____________________________________________________State:_______________ZIP:_____________________

__________________________________________________________________________

______________________

Seller’s Signature

Date

********************************************************************************************************************************************************

I, the undersigned, certify that the above described vehicle has been acquired as junk, parts only, or scrap.

Acquiring Business’s Name:______________________________________________________________________________

Street Address:________________________________________________________________________________________

City:________________________________________________State:_________________ ZIP:_______________________

NMVTIS ID Number:_____________________________ Date of Acquisition_______________________________________

____________________________________________________________________________________________________

Business Agent’s Signature, Printed Name, and Title

This form must be mailed by the used motor vehicle parts dealer or scrap metal processor to the Department

of Revenue within seventy-two (72) hours of the completed transaction. Forms must be completed by the

Business Agent. Incomplete forms will be rejected.

***Disclosure Statement and Privacy Act Notice***

Driver’s License Numbers are required by State Law and will be used in the administration of State Motor Vehicle Laws. The Department is authorized to collect the information pursuant to 42 U.S.C. Section 405 (c)(2)(C) and Miss.

Code Ann. Section 63-21-15. Titles and Registration records may be released only pursuant to 18 U.S.C. Sections 2721-2725. Failure to provide the information will result in the denial of a certificate of title.

DO NOT WRITE IN THIS SPACE - FOR INTERNAL USE ONLY

Title Bureau

P. O. Box 1033

Jackson, MS 39215

Phone 601-923-7641