Fillable Form Vsa 40 - Vehicle Removal Certificate printable pdf download

VEHICLE REMOVAL CERTIFICATE

VSA 40 (10/01/2011)

Purpose:

This form is used by any person (individual, business, government; see VA Code §1-230) or their authorized agent(s) to track and record

the removal and/or disposition of a motor vehicle, trailer or manufactured home in their possession.

Instructions: Complete and submit this form following the instructions on the back of the form.

1. VEHICLE/TRAILER/MANUFACTURED HOME INFORMATION

VEHICLE YEAR VEHICLE MAKE

VEHICLE MODEL

VEHICLE IDENTIFICATION NUMBER (VIN)

STATE

VEHICLE LOCATION

CITY

ZIP CODE

VEHICLE TYPE

AUTO

MANUFACTURED HOME

MOTORCYCLE

TRAILER

TRUCK

OTHER _________________

TELEPHONE NUMBER

FULL NAME OF PERSON/AUTHORIZED AGENT IN POSSESSION OF VEHICLE

(

)

ADDRESS OF PERSON/AUTHORIZED AGENT IN POSSESSION OF VEHICLE CITY

STATE

ZIP CODE

I certify and affirm that all information presented in this section is true and correct, that any documents I have presented to DMV are genuine, and that the information

included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a

false statement or representation on this form is a criminal violation.

SIGNATURE OF PERSON/AUTHORIZED AGENT IN POSSESSION OF VEHICLE

DATE (mm/dd/yyyy)

2. TOWING COMPANY INFORMATION AND CERTIFICATION

The vehicle described

LICENSED VEHICLE REMOVER'S COMPANY NAME

BTRO LICENSE NUMBER (or tow truck plate number)

→

above was released to

ADDRESS

CITY

STATE

ZIP CODE

OPERATOR NAME (print)

TOWING COMPANY REPRESENTATIVE NAME (print) (if different than operator)

I certify and affirm that all information presented in this section is true and correct, that any documents I have presented to DMV are genuine, and that the information

included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a

false statement or representation on this form is a criminal violation.

TOWING COMPANY REPRESENTATIVE SIGNATURE

DATE (mm/dd/yyyy)

3. VEHICLE DISPOSITION

I certify and affirm that I have complied with all requirements of the Virginia Motor Vehicle law for the above vehicle, trailer, or manufactured home and am:

obtaining title in my name (signature required below),

selling at auction (complete section 4),

transferring to a demolisher or scrap metal processor.

(complete section 5)

I further certify and affirm that all information presented in this section is true and correct, that any documents I have presented to DMV are genuine, and that the information

included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a

false statement or representation on this form is a criminal violation.

SIGNATURE OF PERSON/AUTHORIZED AGENT IN POSSESSION OF VEHICLE

DATE (mm/dd/yyyy)

4. SALE OF ABANDONED VEHICLE (AVP) INFORMATION

The vehicle described

PURCHASER NAME (print)

→

above was sold to

ADDRESS

CITY

STATE

ZIP CODE

ONLINE AVP RECEIPT NUMBER (if applicable)

PURCHASE PRICE

PURCHASE DATE (mm/dd/yyyy)

I certify and affirm that I have complied with all requirements of the Virginia Motor Vehicle law for the above abandoned vehicle, trailer or manufactured home and am eligible

to transfer ownership to a third party. I further certify and affirm that all information presented in this section is true and correct, that any documents I have presented to DMV

are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I

understand that knowingly making a false statement or representation on this form is a criminal violation.

SELLER SIGNATURE

DATE (mm/dd/yyyy)

DMV HQ USE ONLY

Is the vehicle identification number (VIN) on the customer service system (CSS)?

YES

Is the vehicle currently registered?

YES

If VIN is not on CSS, is Abandoned Vehicle Receipt attached?

Has the vehicle been previously entered as demolished?

YES

Is the vehicle recorded as stolen?