Form T-22b - Certification Of Inspection By A Duly Constituted Georgia Law Enforcement Officer

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T-22B (Rev. JULY 2013)
State of Georgia
All Previous Revisions are Obsolete
Department of Revenue
Motor Vehicle Division
Certification of Inspection by a Duly Constituted Georgia Law Enforcement Officer
VEHICLE DESCRIPTION
YEAR
MAKE
MODEL
BODY STYLE
COLOR
INSPECTION OF PUBLIC (PVIN) AND MOTOR VEHICLE SAFETY LABEL (FEDERAL STICKER)
VISABLE THROUGH WINDSHEILD?
PVIN
FEDERAL
LOCATION?
STICKER
PUBLIC VEHICLE IDENTIFICATION NUMBER ATTACHED (CIRCLE APPROPRIATE RESPONSE)
ROSETTE RIVETS
SCREWS
ADHESIVE
MISSING/NOT
DESCRIBE CONDITION
VISIBLE
Has the manufacturer affixed a National Highway Transportation Safety Administration (NHTSA) Label certifying the vehicle,
motorcycle or scooter conforms to applicable U.S. Federal Motor Vehicle Safety Standards (FMVSS)?
YES
NO
SUPPORTING DOCUMENTATION ESTABLISHING OWNERSHIP OF THE APPLICANT
CERTIFICATE OF TITLE/STATE
TAG INFO – (LAST KNOWN
MANUFACTURER
IF NO TITLE OR TAG, DESCRIBE
OF ISSUANCE
REGISTRATION AND STATE)
STATEMENT OF ORIGIN
DOCUMENTS PRESENTED
PERSON IN POSSESSION OF VEHICLE
FULL LEGAL NAME
DRIVERS LICENSE #
RESIDENTIAL or BUSINESS ADDRESS
APARTMENT #
PHONE NUMBER
CITY
STATE
ZIP CODE
COUNTY
CERTIFICATION OF GEORGIA LAW ENFORCEMENT OFFICER
FULL LEGAL NAME
BADGE NUMBER
AGENCY NAME & PHONE NUMBER
OFFICIAL TITLE/RANK
AGENCY ADDRESS
CITY, COUNTY
GCIC/NCIC RESPONSE TO STOLEN INQUIRY (GCIC/NCIC DATE/TIMESTAMP)
DATE/TIME
The signature of the duly constituted law enforcement officer examining this vehicle certifies pursuant to
DOR Rule 375-2-12-.08, that said officer completed this form and conducted an inquiry on the Georgia
Crime Information Center’s (GCIC) and/or National Crime Information Center’s (NCIC) stolen vehicle files
to establish the status of this vehicle under the penalty of false swearing (O.C.G.A. §16-10-71).
____________________________________________________
____________________________
SIGNATURE
DATE
REMARKS:
All Previous Revisions are Obsolete
Any strike-over or corrections void this form. This form must be printed and legible and is valid only when
completed-in-full and signed by a Georgia Law Enforcement Officer.

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