Form Vs-20 - Facility Out Of Business Attestation
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1
2FACILITY OUT OF BUSINESS ATTESTATION
Use this form to notify the Department of Motor Vehicles that your Vehicle Safety-regulated facility is
out of
INSTRUCTIONS:
permanently
business, and for instructions about surrendering the DMV items that have been issued to you. If your facility will be
out of business,
temporarily
please contact the appropriate Vehicle Safety Field Services Regional Office for instructions.
− Enter your facility information
STEP 1
Facility E-mail Address
Facility Number
Facility Telephone Number
(
)
Facility Contact Person
Date Out of Business
Facility Name
Facility Address (include street number and name)
City
State
Zip Code
− Indicate
STEP 2
all
facility types that are out of business
¨
¨
¨
¨
Repair Shop
Mobile Car Crusher
Yacht Broker
Itinerant Vehicle Collector
¨
¨
¨
¨
Inspection Station
Vehicle Dismantler
ATV Dealer
Out-of-State Junk & Salvage
¨
¨
¨
¨
Motor Vehicle Dealer
Scrap Collector
Scrap Processor
Other:
¨
¨
¨
Transporter
Snowmobile Dealer
Salvage Pool
_____________________________
¨
¨
Drive-In Appraisal
Boat Dealer
− Surrender the DMV items that were issued to each facility that is permanently out of business (see additional instructions on page 2
STEP 3
of this form). All items surrendered to the Bureau of Consumer & Facility Services must be shipped with this form.
I certify that I am the owner, partner, principal or officer of the business named in this request form, and that the information contained on
this form is true and complete. The items that must be surrendered to the Bureau of Consumer & Facility Services are being shipped with
this form. All other items have been surrendered to the appropriate DMV office.
If I surrender my public emissions inspection station license, there will be the following consequences:
After the DMV processes this form, the surrender of my license is final and cannot be undone.
l
l
After being placed out of business, if I/we wish to become a public emissions inspection station in the future, I/we will be required
to submit an original application. If I/we apply to become a public emissions inspection station, the application will be for
a new license and, as such, may be subject to placement on a waiting list, as required by 15 NYCRR 79.7(f).
l
I will lose my right to transfer my public emissions inspection station license as allowed by 15 NYCRR 79.7 (f) (3)
I fully understand the consequences of surrendering my public emissions inspection station license.
Print Name
Date
Signature
ç
− Send this form and the items that must be surrendered to the appropriate address for the Bureau of Consumer & Facility Services
STEP 5
(the address depends on the shipping carrier that you use, see page 2). Fill out the table below identifying the items you are
returning and
attach an additional detailed packing list if needed.
DMV-Issued Item
Item/Form Quantity
Beginning Serial #
Ending Serial #
PAGE 1 OF 2
VS- 20 (2/16)
RESET/CLEAR FORM
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