Fillable Form Vsa 10b - Antique License Plate Applicant Certification printable pdf download

VSA 10B (07/01/2014)

ANTIQUE LICENSE PLATE

APPLICANT CERTIFICATION

Purpose:

Owners of antique motor vehicles, antique trailers, antique motorcycles and antique autocycles use this form to certify

compliance with Code of Virginia requirements for use of antique plates.

Instructions:

Return the completed VSA 10 B form (along with a VSA 10, VSA 14 or VSA 17A) with the one-time $50 fee and any other

applicable fees to any DMV customer service center. You may also mail the forms and fees to DMV, Special Plates, P.O.

Box 26668, Richmond, VA 23261-6668.

APPLICANT INFORMATION

OWNER TELEPHONE NUMBER

OWNER FULL NAME (last, first, middile initial) (print)

(

)

CO-OWNER TELEPHONE NUMBER

CO-OWNER FULL NAME (last, first, middile initial) (print)

(

)

STREET ADDRESS

CITY

STATE

ZIPCODE

USE OF ANOTHER VEHICLE, MOTORCYCLE OR AUTOCYCLE

Virginia Code, Section 46.2-730, requires evidence that the applicant named above owns or has regular use of another passenger car,

motorcycle or autocycle. Antique license plates will not be issued without this evidence. The vehicle must have active registration. If the

registration is inactive or the information is incorrect, the certification will not process.

I certify that I own at least one other properly registered vehicle, motorcycle or autocycle. (Describe below)

VEHICLE TITLE NUMBER

VEHICLE IDENTIFICATION NUMBER (VIN)

MAKE

MODEL

LICENSE PLATE NUMBER

I do not own another properly registered vehicle, motorcycle or autocycle; however, I certify that I have regular use of at least one

other properly registered vehicle, motorcycle or autocycle as authorized by the owner/co-owner below.

VEHICLE IDENTIFICATION NUMBER (VIN)

MODEL

VEHICLE TITLE NUMBER

STATE OF TITLE

MAKE

LICENSE PLATE NUMBER

OWNER FULL NAME (last, first, middile initial) (print)

OWNER SIGNATURE

CO-OWNER FULL NAME (last, first, middile initial) (print)

CO-OWNER SIGNATURE

INSURANCE CERTIFICATION

I/We certify that (check one):

This vehicle is insured by a liability policy issued through an insurance company licensed to do business in Virginia and it will remain insured while

registered, whether or not it is operated. Penalties are severe for violation of this requirement.

This vehicle is not insured; therefore, I am remitting the applicable uninsured motor vehicle fee. (This fee provides no insurance coverage.) A

vehicle must be insured with liability coverage when it is registered, and it must remain insured while registered, whether or not it is operated, or the

uninsured motor vehicle fee must be paid. Penalties are severe for violation of this requirement.

USE OF ANTIQUE PLATES

Virginia Code, Section 46.2-730, limits use of antique vehicles, trailers, motorcycles and autocycles registered with antique plates to the participation in club

activities, exhibits, tours, parades and similar events and to carrying or transporting passengers, personal effects and other antique vehicles for show

purposes. They may also be used on Virginia highways to test vehicle/trailer operation, obtaining maintenance or repairs and/or to sell the vehicle or trailer.

Antique plates permit occasional pleasure driving (not to exceed 250 miles from the owner's residence) but are not to be used for general transportation

purposes, including but not limited to, daily travel to and from the owner's place of employment.

PENALTY FOR MISUSE OF ANTIQUE PLATES

Any owner of an antique vehicle, trailer, motorcycle or autocycle registered with license plates pursuant to Virginia Code, Section 46.2-730, will be guilty of a

Class 4 misdemeanor if convicted of a violation of antique plate usage. The conviction will cause the owner's registration for the vehicle involved in the

violation to be revoked for a five-year period from the date of conviction.

VEHICLE SAFETY CERTIFICATION

Virginia Code, Section 46.2-730, requires that you certify that the antique vehicle, trailer, motorcycle or autocycle registered with antique plates is capable of

being safely operated on Virginia highways.

VEHICLE TITLE NUMBER

VEHICLE IDENTIFICATION NUMBER (VIN)

MAKE

MODEL

LICENSE PLATE NUMBER

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

information included in all supporting documentation is true and accurate. I/We make this certification and affirmation under penalty of perjury and I/we understand

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

OWNER SIGNATURE

CO-OWNER SIGNATURE

DATE (mm/dd/yyyy)