Fillable Form Vsa 40 - Vehicle Removal Certificate (Page 2 of 2) in pdf

VSA 40 (10/01/2011)

Page 2

5. DEMOLISHER/SCRAP METAL PROCESSOR INFORMATION AND CERTIFICATION

As provided under VA Code, I have transferred possession of the above described vehicle to the licensed demolisher or scrap metal processor listed below for the purpose

of demolition or conversion to scrap.

INDIVIDUAL/AUTHORIZED AGENT SIGNATURE (Transferor)

VEHICLE TRANSFER DATE (mm/dd/yyyy)

TELEPHONE NUMBER

DEMOLISHER/SCRAP METAL PROCESSOR COMPANY NAME (Transferee)

BUSINESS LICENSE NUMBER

(

)

CHECK ONE OF THE FOLLOWING OR STAMP THE BLANK SPACE BELOW WITH APPROVED MERCURY SWITCH STAMP:

The mercury switches have been removed from the vehicle, were previously removed from the vehicle, or the vehicle was not manufactured with

mercury switches.

The mercury switches could not be removed from the vehicle because upon attempt it was determined removal of the switches would be

impractical, unreasonable or unsafe.

I certify that the vehicle has been demolished/scrapped. 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.

DEMOLISHER/SCRAP METAL PROCESSOR REPRESENTATIVE SIGNATURE

DATE DEMOLISHED OR SCRAPPED (mm/dd/ yyyy)

INSTRUCTIONS

Section 1: The person or authorized agent in possession of the vehicle, trailer or manufactured home completes the vehicle and

applicant information, and signs.

Section 2: The licensed vehicle remover completes and signs this section if the vehicle is towed. DMV must receive the original VSA

40 form.

Section 3: The person or authorized agent in possession of the vehicle, trailer or manufactured home must indicate his or her intent to

title, sell or transfer the vehicle, trailer or manufactured home for demolition.

Section 4: The person or authorized agent in possession of a vehicle, trailer, or manufactured home that has been processed using

DMV's online Abandoned Vehicle Process (AVP), completes this section and provides the purchaser with the AVP receipt

and the completed, signed VSA 40 for use in titling the vehicle unless transferred directly to a licensed demolisher (See

Section 5).

Section 5: The person or authorized agent transferring possession of the vehicle, trailer or manufactured home to a licensed

demolisher or scrap metal processor signs this section and transfers this form with the vehicle to the demolisher/scrap

metal processor. The licensed demolisher or scrap metal processor completes this section to certify that the vehicle, trailer

or manufactured home was demolished or scrapped. A license number, signature, date and telephone number are

required.

Manual Reporting of Vehicle Disposition to DMV:

Licensed demolishers or scrap metal processors, who do not report vehicle disposition electronically per Va. Code

§46.2-1608.2, return the original VSA 40 form and applicable documents as required to DMV at the following address:

Virginia Department of Motor Vehicles

Data Integrity Room 516

Post Office Box 27412

Richmond, Virginia 23269-0001

NOTE: A copy of this VSA 40 form must be retained by the demolisher/scrap metal processor in accordance with the

requirements in VA Code §46.2-1206.

Electronic Reporting of Vehicle Disposition to DMV:

Licensed demolishers or scrap metal processors who report vehicle disposition electronically to DMV per Va. Code

§46.2-1608.2 shall retain the original VSA 40 form, proof of ownership document(s) and applicable DMV forms (as

required), on file in a secure location for at least five years in accordance with the requirements in Va. Code §46.2-1206.

These files are subject to inspection by law-enforcement.

COMMENTS (Use the area below to enter any additional information.)

Form Vsa 40 - Vehicle Removal Certificate Page 2

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