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555 WRIGHT WAY

CARSON CITY, NV 89711-0700

Reno/Sparks/Carson City (775) 684-4DMV (4368)

Las Vegas Area (702) 486-4DMV (4368)

Rural Nevada or Out of State (877) 368-7828

CERTIFICATE OF INSPECTION FOR REBUILT VEHICLES (NOT SALVAGE)

NRS 482.098, NRS 482.220 & NRS 482.223

OWNERSHIP DOCUMENTS MUST ACCOMPANY THIS FORM FOR THE DEPARTMENT TO TITLE OR REGISTER

Instructions



All parts of this form must be completed.



Part I must be completed by a Nevada Registered Garage, Licensed Nevada Body Shop or Rebuilder.



Part II must be completed by the vehicle owner and verify with a Nevada DMV Agency Representative or Notary Public.



Part III must be completed by a Nevada DMV Agency Representative.

Important: Corrections on this form will not be accepted. – If a mistake is made, you must complete a new form.

PART I

Safety Inspection

Must be completed by a Nevada Registered Garage, Licensed Nevada Body

Shop,

or Rebuilder

Year____________________ Make__________________________ Model__________________________ Type___________________

Vehicle Identification Number (VIN)

Check () the Appropriate Box(es) to indicate components replaced.

 Cowl

 Rear clip

 Roof assembly

 Floor pan assembly

 Complete front inner structure of a unibody

 Conventional frame & one major component

NOTE: In addition to all other disclosures, by signing Part I below the affiant attests that the item(s) checked have been installed to the

applicable standards of the manufacturer and the automotive repair industry and are in a safe operating condition.

Please Print or Type

Legal Business Name ___________________________________________________________________________________________

Name

DMV Business License or Registration Number

Address_______________________________________________________________________________________________________

City

State

Zip Code

By signing this document, I certify the described vehicle is mechanically safe to operate. I further certify the items indicated have been

satisfactorily repaired to the applicable standards of the manufacturer and the motor vehicle repair industry. In addition, I certify any

safety equipment including occupant restraint devices, which were present in the vehicle at the time the vehicle was manufactured are

present and operational to the standards of the manufacturer.

__________________________________________

___________________________________________ __________

Printed Full Legal Name of Affiant

Signature and Position

Date

PART II

AFFIDAVIT OF CONSTRUCTION FOR A REBUILT MOTOR VEHICLE

The undersigned, being duly sworn upon oath, deposes and says they are the owner of the vehicle described on this document. This

vehicle was rebuilt from parts and materials on hand, or parts and materials purchased from a supplier, or otherwise lawfully acquired.

The affiant or registered owner makes this affidavit as part of an application to the Nevada Department of Motor Vehicles for a Certificate

of Registration and/or a Certificate of Title. The undersigned will indemnify and hold harmless the State of Nevada on account of the

issuance of a Certificate of Registration and/or Certificate of Title for said vehicle.

 Vehicle was rebuilt from parts/material on hand

 Vehicle was rebuilt from purchased parts/material, receipts attached

_________ ______________________________________ ___________________ ____________________ ________

Year

Make

Model

Type

No. of axles

Please Print or Type

Affiant’s Full Legal Name _________________________________________________________________________________________

(As appears on Drivers License)

First

Middle

Last

NV Driver’s License, ID Number, or DOB ___________________________________________ Telephone Number (____)____________

Affiant’s Physical Address

________________________________________________________________________________________________

City

State

Zip Code

Affiant’s Mailing Address

_________________________________________________________________________________________________

City

State

Zip Code

Affiant’s Signature _______________________________________________________________________ Date___________________

______________________________________ ____________________________________ ___________

_________

Printed name of Nevada DMV Agency Representative

Signature of Nevada DMV Agency Representative

ID No.

Date

Or Notary Public

VP-64A (6-2011)

Form Vp-64a - Certificate Of Inspection For Rebuilt Vehicles (Not Salvage) - (Vp 064a)

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