Form Vsa 22 - Application For Assigned Vehicle Identification Number

Download a blank fillable Form Vsa 22 - Application For Assigned Vehicle Identification Number in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Vsa 22 - Application For Assigned Vehicle Identification Number with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

VSA 22 (04/10/2016)

APPLICATION FOR ASSIGNED

VEHICLE IDENTIFICATION NUMBER

DMV USE ONLY

VIN PLATE ASSIGNED

Purpose:

Use this form to apply for an assigned vehicle identification

number.

Instructions:

Return the completed form to DMV at the above address.

VEHICLE INFORMATION

MAKE

BODY TYPE

NUMBER OF AXLES

YEAR OR CONSTRUCTION DATE (mm/dd/yyyy)

CURRENT VEHICLE IDENTIFICATION NUMBER (VIN, if any)

OWNER INFORMATION

OWNER NAME

(last, first, mi, suffix)

CUSTOMER NUMBER/FEIN/SSN

PRIMARY TELEPHONE NUMBER

(

)

STREET ADDRESS

ALTERNATE TELEPHONE NUMBER

(

)

CITY

STATE

ZIP CODE

CO-OWNER NAME

(last, first, mi, suffix)

CUSTOMER NUMBER/FEIN/SSN

PRIMARY TELEPHONE NUMBER

(

)

CO-OWNER STREET ADDRESS

ALTERNATE TELEPHONE NUMBER

(

)

CITY

STATE

ZIP CODE

REASON FOR APPLICATION

Check one. Please note document and fees required.

SPECIALLY CONSTRUCTED VEHICLE - Original title, bills of sale,

MISSING, CHANGED OR ALTERED PLATE - Original title in your

certificate of origin, and notarized statement of construction; photo of

name and $140.00 fee. ($5.00 VIN application, $125.00

vehicle; and $130.00 fee. ($5.00 VIN application, $125.00 examination fee.)

examination fee, and $10.00 substitute title fee.)

HOMEMADE TRAILER - (Complete the Homemade Trailer

RECONSTRUCTED VEHICLE - Same as above.

Information Section) ($5.00 fee.)

REPLICA VEHICLE - Same as above.

COMPLETE ONLY FOR HOMEMADE TRAILER

TRAILER TYPE (check one)

BOAT TRAILER

UTILITY TRAILER

CAMPING TRAILER

HORSE TRAILER

OTHER (specify)

If you were not involved in the actual construction of this trailer, enter the builder's name and address below.

BUILDER NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

APPLICANT CERTIFICATION

I certify that if this application is for a homemade trailer, I personally was involved in its construction or that the trailer was purchased as homemade. I further

certify and affirm that all information presented in this form 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.

APPLICANT NAME (print)

APPLICANT SIGNATURE

DATE (mm/dd/yyyy)

CERTIFICATION OF INSTALLED VEHICLE IDENTIFICATION NUMBER

This certification must be signed by a Virginia Law Enforcement Officer and returned to DMV with an Application for Title and Registration (VSA- 17A) before

a title and license plate(s) can be issued.

NOTE: For a reconstructed vehicle, specially constructed vehicle, replica motor vehicle or a vehicle missing the Vehicle Identification Number (VIN); a DMV

special agent must install the assigned VIN plate and certify its installation below.

I certify that the assigned Vehicle Identification Number has been attached to the vehicle described below.

SIGNATURE

AGENCY

DATE (mm/dd/yyyy)

BADGE NUMBER