Form Ps2015a-14 - Declaration Of Reconstruction/special Assembly
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5MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES DIVISION
445 MINNESOTA ST.
ST. PAUL, MN 55101
DECLARATION OF RECONSTRUCTION/SPECIAL ASSEMBLY
It is against Federal and State laws to tamper with or remove a vehicle identification number (VIN) plate or label. Destruction, removal,
alteration, covering or defacement of the original vehicle identification number may be cause for the Department to refuse to title or register your
vehicle. Reconstructed and specially assembled vehicles are subject to a motor vehicle inspection.
Side A - Cars/Trucks/Pickups
This declaration must accompany the application to title your reconstructed or specially assembled vehicle. Original titles, manufacturer's
certificates of origin and/or receipts for all major parts used in the reconstruction must accompany this declaration. Please refer to the Guide for
Reconstructed Vehicles for minimum proof of ownership requirements.
Current License Plate Number:
Current Title Number:
Part
Part Number/VIN of Parts Vehicle
Obtained From
Body Cab
Frame Chassis
Doors
Fender
Bumper
Quarter Panel
Front End Assembly
Rear Clip
Engine
Transmission
Hood
Roof
Other Changes:
Describe fully any other changes such as cutting down the body or frame, changes of springs, wheels, axles, etc.
The person who made the repairs must sign this form.
Important: Minnesota Statute 168A.30 provides that falsifying information on any required document shall be guilty of a felony.
This serves as written confirmation to the Department of Public Safety that the vehicle to be titled meets the requirements of M.S. Chapter
169 for vehicles in its class regarding safety and acceptability to operate on public roads and highways.
Owner’s Name
Repair Shop Name/Phone
X
Assembler’s/Rebuilder’s Signature
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PS2015A-14 (07/15)
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