Form Vsa 56 - Salvage Certificate Application
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2VSA 56 (07/01/2011)
SALVAGE CERTIFICATE APPLICATION
Purpose:
Use this form to apply for a salvage certificate and/or to report water damage to a vehicle.
Instructions:
Submit the completed application with the estimated cost of repairs to the Vehicle Branding Work Center at
the above address
.
OWNER INFORMATION
OWNER FULL LEGAL NAME (last)
(first)
(middle)
(suffix)
SSN, FEIN OR VA DRIVER'S LICENSE NUMBER
DEALER/REBUILDER NUMBER
TELEPHONE NUMBER
(
)
OWNER STREET ADDRESS
CITY
STATE
ZIP CODE
CO-OWNER FULL LEGAL NAME (last)
(first)
(middle)
(suffix)
SSN, FEIN OR VA DRIVER'S LICENSE NUMBER
EMAIL ADDRESS
LIEN INFORMATION
LIEN DATE (mm/dd/yyyy) LIENHOLDER NAME
Is there a lien on
YES - Complete this section.
this vehicle?
NO - Go to SOURCE INFORMATION section
LIENHOLDER MAILING ADDRESS
CITY
STATE
ZIP CODE
SOURCE INFORMATION
VEHICLE PURCHASED FROM
SALE PRICE
SALES AND USE TAX
PURCHASE DATE (mm/dd/yyyy)
STREET ADDRESS
CITY
STATE
ZIP CODE
CURRENT TITLE ISSUE DATE (mm/dd/yyyy)
CURRENT TITLE NUMBER
STATE
VEHICLE INFORMATION
Check box and enter name of city, county or town where vehicle is principally garaged.
VEHICLE IDENTIFICATION NUMBER (VIN)
CITY
COUNTY
TOWN of ______________________________________________________
MAKE
MODEL
BODY TYPE
VEHICLE COLOR
YEAR
PRIMARY
SECONDARY
EMPTY WEIGHT
GROSS WEIGHT
NUMBER OF AXLES
FUEL TYPE
ACTUAL CASH VALUE
ESTIMATED REPAIRS COST
PERCENT OF DAMAGE
VEHICLE ACQUIRED DATE (mm/dd/yyyy)
INSURANCE COMPANY NAME
INSURANCE CODE NUMBER INSURANCE CLAIM NUMBER CLAIM PAYMENT DATE (mm/dd/yyyy)
WATER DAMAGE CLAIM OF $3,500 OR MORE HAS BEEN PAID BY THE INSURANCE COMPANY
STOLEN VEHICLE
ODOMETER READING
ODOMETER READING (no tenths)
Federal and state law requires that you state the mileage in connection with the transfer of ownership. Failure to
complete the statement or providing a false statement may result in fines and/or imprisonment.
To the best of my knowledge the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked:
The model year is at least 10 years or older than the current calendar year and was
The mileage stated is in excess of its mechanical limits.
exempt from odometer disclosure in the prior state of title. (Applicant must present the
The odometer reading is not the actual mileage.
out-of-state title showing the exemption).
DMV USE ONLY
REASON HELD
SALE PRICE
TAX
NCIC CHECK
TITLE FEE
WITH LIEN
YES
NO
TOTAL
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