Vehicle Registration Application {VSA 14}

VSA 14 (07/10/2018) LESSEE'S RESIDENCE/BUSINESS ADDRESS CITY ZIP CODE STATE LESSEE'S FULL LEGAL NAME (last, first, mi, suffix) DMV CUSTOMER NUMBER / FEIN / SSN TELEPHONE NUMBER LEASE INFORMATION (if applicable) REGISTRATION MAILING ADDRESS - OPTIONAL CITY ZIP CODE STATE IF YOU WOULD LIKE YOUR REGISTRATION RENEWALS SENT TO AN ADDRESS OTHER THAN YOUR RESIDENCE/BUSINESS ADDRESS, ENTER IT BELOW. IF NEW LOCATION ENTER DATE CHANGED Are any of the owners/lessees on active military duty or service? YES NO LOCATION WHERE VEHICLE IS PRINCIPALLY GARAGED TOWN OF CITY COUNTY VEHICLE INFORMATION OWNER EMAIL ADDRESS CO-OWNER EMAIL ADDRESS OWNER'S RESIDENCE/HOME/BUSINESS ADDRESS (Apt # if applicable) CITY ZIP CODE STATE CITY ZIP CODE STATE CO-OWNER'S RESIDENCE/HOME/BUSINESS ADDRESS (Apt # if applicable) NOTE: Owners (and Lessees if applicable) MUST provide their residence/home/business address where requested, this address can not be a P.O. Box. You must complete form ISD-01 if you would like your address(es) updated. RESIDENCE/BUSINESS JURISDICTION DMV CUSTOMER NUMBER / FEIN / SSN CO-OWNER'S FULL LEGAL NAME (last, first, mi, suffix) TELEPHONE NUMBER OWNER'S FULL LEGAL NAME (last, first, mi, suffix) OR BUSINESS NAME (if business owned) DMV CUSTOMER NUMBER / FEIN / SSN TELEPHONE NUMBER OWNER INFORMATION Registration Type: (check one) Ridesharing (Vanpool) (Cannot exceed 16 passengers including driver.) Seating Capacity ENTER PLATE NUM Transfer License Plate Number: Reissue (Decals Only) Rental Vehicle SPECIFY Other: For Hire (complete "For Hire Information" section) Specify letters: Amateur Radio Operator Call Letters -- Original Reissue (Plates & Decals) Private RenewalSee Reissue Plates below under Plate Information. Registration Period: (check one) Three Years ($3 discount applies) One Year Two Years ($2 discount applies)(not available for vehicles subject to emissions testing) REGISTRATION INFORMATION PERSONAL PROPERTY TAX RELIEF ELIGIBILITY 1. Answer the questions below to determine if your vehicle qualifies for car tax relief. YESNOa. Is more than 50% of the vehicle's annual mileage used as a business expense for federal income tax purposes OR reimbursed by an employer? b. Is more than 50% of the depreciation associated with the vehicle deducted as a business expense for federal income tax purposes? c. Is the cost of the vehicle expensed pursuant to Section 179 of the Internal Revenue Service Code? d. If the vehicle is leased by an individual, does the leasing company pay the tax without reimbursement from the individual? 2. If you answered YES to ANY of the above questions, check Business Use. Your vehicle is considered by State law to have a business use and does NOT qualify for Personal Property Tax Relief. 3. If you answered NO to ALL of the above questions, check Personal Use and answer the question below. BUSINESS USE PERSONAL USE -- Is this vehicle held in a private trust for non-business purposes by an individual beneficiary? YES NO EMPTY WEIGHT GVWR WEIGHT SINGLE VEHICLE (manufacturer) GCWR COMBINED WEIGHT (truck & attached trailer) VEHICLE COLOR PRIMARY AGENCY CODE TITLE NUMBER STATE IS VEHICLE STATE OR LOCALITY-OWNED? NO YES - enter agency code GROSS WEIGHT (truck & attached trailer) FUEL TYPE OTHER DIESEL ELECTRIC GASOTHER FUEL TYPE DIVISION CODE IS THIS A LOW SPEED VEHICLE? NO YES IS THIS A LOGGING VEHICLE? NO YESPurpose: Use this form to apply for registration of your vehicle. Note: You must obtain a Virginia vehicle safety inspection sticker and pay any required local vehicle registration fees to your city or county. For the City of Virginia Beach only, DMV collects local vehicle registration fees. Instructions: Refer to the Registration Information Sheet (VSA 14I) for general registration information. All owners must sign the Certification section. Mail completed form with a check or money order (made payable to DMV) to the Titling Work Center at the above address, or present to any DMV Customer Service Center (CSC) or DMV Select. Note: A $5 service fee per vehicle applies to each renewal transaction conducted in a CSC, unless the renewal is conducted with another transaction that cannot be completed by internet, automated telephone, mail or at a DMV Select. A $10.00 late fee will be charged if registration is renewed after the expiration date.VEHICLE REGISTRATION APPLICATION VEHICLE IDENTIFICATION NUMBER (VIN) YEAR MAKE MODEL BODY TYPE NUMBER OF AXLES CURRENT PLATE NUMBER American LegalNet, Inc. www.FormsWorkFlow.com VSA 14 (07/10/2018) -- Page 2 DAYTIME TELEPHONE NUMBER ( ) DAYTIME TELEPHONE NUMBER ( ) CO-APPLICANT SIGNATURE DATE (mm/dd/yyyy) APPLICANT/AUTHORIZED CORPORATION/COMPANY REPRESENTATIVE SIGNATURE DATE (mm/dd/yyyy) 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. If the vehicle to be registered has a gross weight of 26,001 pounds or more, I/we further certify and affirm my/our knowledge of all applicable state and federal motor carrier safety and hazardous materials laws and regulations. If I/we have requested Amateur Radio Operator Call Letter license plates, I/we certify and affirm that I/we will return those plates to DMV for another type of license plate within 90 days if my/our amateur radio license becomes invalid for any reason. An authorized representative must sign for a corporation or company. CERTIFICATION New Plates: (check one) Reissue Plates: (check one) Lost Mutilated/Destroyed Illegible Confiscated I want a new plate design/character combination Small size plate (trailer gross weight must be 4,000 lbs or less) Regular size plate Trailer Permanent - one-time fee (check one): For Hire Plate (enter description): (examples: Taxi, Passenger For Hire, Tow Truck, etc.) PERSONALIZED LICENSE PLATES: To request personalized license plates, check this box and enter your choices below. 1st 2nd 3rd 4th Farm Plate - You must ALSO complete the Farm Vehicle Plate Certification (VSA 131).may be issued to trailers, travel trailers, or semi-trailers; trucks/tractor trucks with a GVWR or GCWR of more than 26,000 lbs.; trucks/tractor trucks with GVWR or GCWR of 7,501 to 26,000 lbs. if used for business only; farm vehicles registered pursuant to 247 46.2-698; taxicabs or other motor vehicles performing a taxicab service; common carrier vehicles Special Plate (enter type below) Great Seal Heritage (Dogwood-Cardinal) Standard - (Virginia is for Lovers) Autumn Patriot Mountain to Seashore Permanent Plate -Note: Virginia offers more than 200 unique plates for our citizens. Please visit www.dmvNow.com for a listing of special plates available. Not all plates are available for all vehicle types and some special plates require a certification form. Review our website for additional information. PLATE INFORMATION DMV USE ONLY CSR STAMP LICENSE PLATE NUMBER CSC TRANSACTION FEE (TOTAL RENEWALS X $5) CHECK IF NO FEE DECAL MONTH DECAL YEAR ADDITIONAL FEE REGISTRATION FEE REISSUE FEE UMV FEE FEE TOTAL Check to indicate how the vehicle being registered will be used. (check all that apply) Do you hold a valid intrastate operating authority certificate/permit? If no, and you are a passenger carrier you must also complete the For-Hire Vehicles Registration Request (MCS115). Common Carrier - Regular Route Employee Hauler Sight-seeing Carrier Property Carrier * Common Carrier - Irregular Route Contract Passenger Carrier Non-Emergency Medical Transport Household Goods Carrier * Nonprofit/Tax-Exempt Taxicab Exempt Operations - Passengers * Exempt Operations - Property * * You must also complete the For-Hire Vehicles Registration Request (MCS115) PROPERTY CARRIER OPERATIONS PASSENGER CARRIER OPERATIONS YES NO FOR HIRE INFORMATION INSURANCE CERTIFICATIONI/We certify that (check one): This vehicle is insured by a liability policy issued through an insurance company licensed to do bus