Application Form For Nonrepairable Or Salvage Certificate

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MV-6 (4-09)
Application for
Nonrepairable or
Salvage Certificate
Bureau of Motor Vehicles
See Instructions
1101 S. Front Street
on Reverse
Harrisburg, PA 17104
For Department Use Only
(PRINT OR TYPE ALL INFORMATION IN FULL)
Check  Proper Block
K
K
K
1.
Original Certificate of Salvage
2.
Duplicate Certificate of Salvage
3.
Nonrepairable Certificate
K
Check here
if vehicle is a total loss due to flood - (salvage certificate will be branded with a “W”.)
K
if vehicle is a total loss due to theft - (salvage certificate will be branded with a “N”.) NOTE: A copy of the police report, indicating that
Check here
the vehicle was stolen, must be attached or Section E completed.
A
APPLICANT INFORMATION
PA DL/PHOTO ID #
DATE OF BIRTH
LAST NAME (OR FULL BUSINESS NAME)
FIRST NAME
MIDDLE NAME
OR BUS. ID#
DATE OF BIRTH
PA DL/PHOTO ID #
CO-OWNER LAST NAME
FIRST NAME
MIDDLE NAME
STREET ADDRESS TO WHICH CERTIFICATE IS TO BE DELIVERED
CITY
STATE
ZIP CODE
B
VEHICLE DESCRIPTION
TITLE NO.
VEHICLE IDENTIFICATION NUMBER
YEAR
MAKE
OWNER’S NAME AS PRINTED ON FACE OF ATTACHED TITLE
Tenths
I/We certify to the best of my/our knowledge that the odometer reading is ____ ____ ____ , ____ ____ ____
miles and reflects the actual
X
mileage of the vehicle, unless one of the following boxes is checked:
K
K
Reflects the amount of mileage in
is NOT the actual mileage.
excess of its mechanical limits
Warning: Odometer discrepancy.
WARNING: FEDERAL AND STATE LAWS REQUIRE THAT YOU STATE THE MILEAGE IN CONNECTION WITH THIS APPLICATION. FAILURE TO COMPLETE OR PROVIDING A FALSE STATEMENT
MAY RESULT IN FINES AND OR IMPRISONMENT.
C
VEHICLE IDENTIFICATION NUMBER VERIFICATION
NOTE: IF AN OUT-OF-STATE TITLE IS ATTACHED TO THIS APPLICATION, A TRACING OF THE VEHICLE’S IDENTIFICATION NUMBER MUST
BE AFFIXED IN THE SPACE PROVIDED. IF A TRACING CANNOT BE OBTAINED, THE VEHICLE’S IDENTIFICATION NUMBER MUST BE
VERIFIED BY A CERTIFIED INSPECTION MECHANIC OR AUTHORIZED NOTARY PUBLIC IN THE APPROPRIATE SPACES BELOW.
TAPE VIN
TRACING
HERE
AUTHORIZED NOTARY PUBLIC OR CERTIFIED INSPECTION MECHANIC (PRINT NAME)
DIN/MECHANIC #
AUTHORIZED NOTARY PUBLIC OR CERTIFIED INSPECTION MECHANIC SIGN HERE
I CERTIFY THAT A LEGIBLE TRACING CANNOT BE
SECURED AND THAT THE ABOVE VIN IS CORRECT
D
APPLICATION FOR DUPLICATE
K
K
K
K
K
REASON:
LOST
STOLEN
DEFACED
NEVER RECEIVED
* OTHER
(Certificate Must Be
Attached)
* PLEASE EXPLAIN
E
REPORTED TO STATE POLICE - Complete the following
INCIDENT NO.
TELEPHONE NO.
DATE
STATION
(
)
BADGE NO.
NATURE OF INCIDENT
INVESTIGATOR
F
SIGNATURES
I/We certify that all information provided on this application is true and correct.
(
)

TELEPHONE NUMBER
SIGNATURE OF APPLICANT OR AUTHORIZED PERSON

SIGNATURE OF CO-APPLICANT
DATE

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