Form Les 022a - Request For Examination Of Rebuilt Salvage Vehicle

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REQUEST FOR EXAMINATION

LES 022A (07/25/2017)

OF REBUILT SALVAGE VEHICLE

Purpose:

Use this form to request an examination of a rebuilt salvage vehicle.

Instructions:

Complete this form and return it to DMV at the above address along with the required documents and fees. If you have questions about

requesting an examination contact DMVDirect at (804) 497-7100 or visit us on the web at

NOTE: You must be licensed as a rebuilder to have two or more salvage vehicles examined within a 12 month consecutive period.

DOCUMENTS & FEES REQUIRED FOR PROCESSING

Virginia Salvage Title In Your Name -

Completed LES 022A - VA Salvage Title - Title Fee $10 - Exam Fee $125

Completed LES 022A - VA Salvage Title - Salvage Certificate Application (VSA56) - Bill of Sale -

Virginia Salvage Title Assigned To You -

4.15% Sales Tax or minimum $75 whichever is greater - Title Fee $10 - Exam Fee $125

Completed LES 022A - Out-of-State Title - Salvage Certificate Application (VSA56) - Bill of Sale (if title is not in

Out-of-State Salvage Title In Your Name (or)

your name) - 4.15% Sales Tax or minimum $75 whichever is greater - Proof of Sales Tax paid in another state

Out-of-State Salvage Title Assigned To You -

(if paid) - Title Fee $10 - Exam Fee $125

REQUESTERS INFORMATION

INDIVIDUAL/COMPANY NAME (print - last, first, middle, suffix)

DRIVER LICENSE NUMBER/FEIN

STREET ADDRESS (no P.O. Box)

CITY

STATE

ZIP CODE

VEHICLE LOCATION ADDRESS (if different from above)

CITY

STATE

ZIP CODE

BEST TIME TO CONTACT YOU

TELEPHONE NUMBER

CELL PHONE NUMBER

EMAIL ADDRESS

(

)

(

)

If you were not involved in the actual repairing of the vehicle, enter the Individual/Company name and address who repaired the vehicle.

INDIVIDUAL/COMPANY NAME (print - last, first, middle, suffix)

STREET ADDRESS (no P.O. Box)

CITY

STATE

ZIP CODE

REBUILDER LICENSE NUMBER

LICENSE EXPIRATION DATE

NMVTIS ID NUMBER

INDEPENDENT DEALER NUMBER

LICENSE EXPIRATION DATE

VEHICLE INFORMATION

YEAR

MAKE

MODEL

BODY TYPE

VEHICLE IDENTIFICATION NUMBER (VIN)

# AXLES COLOR

PARTS REPAIRED/REPLACED (must be completed)

REPAIRED

REPLACED

REPAIRED

REPLACED

REPAIRED

REPLACED

REPAIRED

REPLACED

Front Bumper

Right Fender

Left Rear Quarter Panel

Engine

Grill

Left Front Door

Right Rear Quarter Panel

Transmission

Hood

Right Front Door

Trunk

Frame/Unibody

Radiator Support

Left Rear Door

Rear Bumper

Air Bags

Left Fender

Right Rear Door

Roof

Dash

SPECIFY REPAIRS

Water Damaged

or Not Listed:

If you have replaced a Pickup Cab or Frame, vehicle is reconstructed and may need to be assigned a new Vehicle Identification Number.

REQUIREMENTS FOR VEHICLE EXAMINATION

Vehicle MUST be rebuilt prior to submitting this request - painting is optional. If vehicle does not pass the examination or you fail to keep your scheduled

appointment you must request a new examination, submit a new LES 022A and pay the necessary fees.

You may obtain a trip permit to move your vehicle to and

Initial here that the state safety inspection is

Vehicle must have passed a VA State safety

from a VA state safety inspection facility using the below

complete.

inspection after completion of the repairs and

link.

prior to the exam. VA Code § 46.2-1605.

Other items required for the exam - Original part receipts - Photo of the vehicle prior to repairs - Old component parts containing a VIN (if available).

CERTIFICATION (all owners must sign)

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/AUTHORIZED AGENT NAME (print)

OWNER/AUTHORIZED AGENT SIGNATURE

DATE (mm/dd/yyyy)

OWNER/AUTHORIZED AGENT NAME (print)

OWNER/AUTHORIZED AGENT SIGNATURE

DATE (mm/dd/yyyy)