Form Vp-64 - Certificate Of Inspection / Affidavit Of Vehicle Construction (Page 2 of 2) in pdf

PART II

AFFIDAVIT OF CONSTRUCTION FOR REBUILT SALVAGE, RECONSTRUCTED

AND SPECIALLY CONSTRUCTED VEHICLES

The undersigned, being duly sworn upon oath, deposes and says they are the owner of the vehicle listed below. This

vehicle was rebuilt or built from parts and materials on hand, or parts and materials purchased from a supplier, or a

manufactured kit purchased from a supplier, or purchased “as is” from a rebuilder, or otherwise lawfully acquired. The

affiant or registered owner makes this affidavit as part of an application to the Nevada Department of Motor Vehicles for a

Certificate of Registration and/or a Certificate of Title. The undersigned will indemnify and hold harmless the State of

Nevada on account of the issuance of a Certificate of Registration and/or Certificate of Title for said vehicle.

Vehicle was constructed from parts/material on hand

Vehicle was assembled from manufactured kit

Vehicle was built from purchased parts/material, receipts attached

Vehicle was purchased “as is” from rebuilder

Please Print or Type

_________ ____________________________________ ___________________ ____________________ __________

Year

Make (if a manufactured kit)

Model

Type

No. of axles

Affiant’s Full Legal Name

________________________________________________________________________________________________

(As appears on Drivers License or ID)

First

Middle

Last

Drivers License, ID Number, or DOB

Telephone Number

_________________________________________

________________________

Affiant’s Physical Address

________________________________________________________________________________________________

City

State

Zip Code

Affiant’s Mailing Address

_________________________________________________________________________________________________

City

State

Zip Code

Affiant’s Signature

Date

________________________________________________________________________________

__________________

___________________________________

___________________________________ ___________

___________

Printed name of Nevada DMV Agency Representative

Signature of Nevada DMV Agency Representative

ID No.

Date

Or Notary Public

PART III

COMPLETED BY AN AUTHORIZED NEVADA DMV REPRESENTATIVE

Note: Attach copies of any title or purchase documents, supplied by owner, showing information of components used from other vehicles.

VIN & Part ________________________________________ VIN & Part________________________________________

VIN indicated in Part I Verified

Vehicle Inspection Fee

DMV Assigned VIN or Kit Manufacturer’s VIN

VIN Assignment Fee

Different than listed in Part I Year________ Make______________ Model_____________ Type___________________

Reason VIN assigned ________________________________________________________________________________

Odometer Reading (as shown on apparatus)

NO TENTHS

If the vehicle’s odometer apparatus only displays five numbers, please put an X in the first box.

1. The mileage stated is in excess of its mechanical limits.

2. The odometer reading is not the actual mileage. WARNING – ODOMETER DISCREPANCY

3. Exempt – Model year over 9 years old.

This vehicle was restored prior to authorization. The undersigned is authorizing restoration after the fact on this form in

lieu of form VP-209.

Additional comments: ________________________________________________________________________________

________________________________ ______________________________ ______ ___________

Printed Name of Nevada DMV Agency Representative

Signature of Nevada DMV Agency Representative

ID NO.

Date

VP-64 (Rev 6/2011)

Form Vp-64 - Certificate Of Inspection / Affidavit Of Vehicle Construction Page 2

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