78021168LC

This Form is to be typed or legibly printed using blue or black ink.

APPLICATION FOR INSPECTION OF A SALVAGE/REBUILT VEHICLE

AND

PROCEDURE FOR OBTAINING CERTIFICATE OF TITLE FOR SALVAGE AND REBUILT VEHICLES

Form 78-021-17-8-1-000 (Rev. 08/17)

MISSISSIPPI DEPARTMENT OF REVENUE

MOTOR VEHICLE SERVICES

POST OFFICE BOX 1383

JACKSON, MS 39215

(

COMPONENT PARTS AS DEFINED IN TITLE 35 PART VII OF MISSISSIPPI ADMIN. CODE)

1). The process begins when a vehicle becomes a total loss, as determined by the insurance company, due to an occurrence. If the vehicle is acquired

by an insurer in the claim settlement process, the insurer applies for a new Certificate of Title of a salvage vehicle for all vehicles acquired, including

an unrecovered theft, EXCEPT when:

a. A vehicle is ten years old or older AND has a value of one thousand-five-hundred dollars ($1,500) or less, or

b. A vehicle will require the replacement of five or fewer minor component parts

If the insurer is unable to determine precisely that five or fewer minor component parts must be replaced in rebuilding the vehicle,

apply for a salvage title.

cow

l or firewall, 2) front-end assembly,

3) rear clip including roof panel, 4) roof panel when installed separately,

5) motor or engine (replaced), 6) frame, or any portion thereof, or in the case of a unitized body, the supporting structure which

each door,

3) each fender or quarter panel,

5) each bumper,

2. The term component parts as pertaining to passenger

vehicle shall mean:

a. Major

component parts -

7) any combination of five minor component parts.

serves as the frame,

b. Minor component parts -

7) transmission/transaxle (replaced)

c. As used in this section -

1) front-end assembly means all of the following: hood, fenders, bumpers, radiator supports, and supporting

members for such items. In the case of a unitized body, the front-end assembly includes frame support members; and

2) rear clip means all of the following: roof, quarter panels, trunk lid, floor pan, and the support members of such item.

d. Truck, truck type, or bus type vehicles -

a component part shown in 2 and not listed in this section which is common to a truck, truck type, or bus

type vehicle should be listed if repaired or replaced.

1. ea

ch door,

2. hood,

3. each fender or quarter panel,

4. each bumper,

1. engine or motor,

2. transmission or transaxle,

3. frame,

4. front fork,

5. tailgate.

a. Major component parts -

1. frame or any portion thereof or, in the case of a unitized body, the supporting structure which serves as the frame,

2. cab,

3. cargo compartment floor panel or passenger compartment floor pan,

4. transmission or transaxle (replaced),

5. motor or engine (replaced),

6. roof panel.

b. Minor component parts are

c. Motorcycle -

a. Component parts -

5. crankcase.

3) When

the insurer has sold the vehicle to a re-builder, the re-builder is not required to apply for a new Certificate of Title until the vehicle has

been rebuilt, at which time he must apply for a new Certificate of Title in his or her name.

Once the vehicle has been rebuilt and is ready for inspection, a complete Application for Inspection of Salvage/Rebuilt Vehicle, (Form 78-021), four

pictures, and arrange with the Department of Public Safety to have said vehicle inspected. At the time of inspection, the following

documentation must be presented:

Application for inspection of a Salvage/Rebuilt Vehicle, (Form 78-021); and

1. notarized bills of sale for each major component part, including: name and address of person the part was purchased from, the year, make,

model, and vehicle identification number of vehicle from which the part was removed,

2. invoice for each minor component part, containing complete information as to source, etc., except notarization not required (see 1 immediately

preceeding),

3. original Application of Certificate of Title wherein the re-builder is shown as owner (re-builder required to title prior to re-sale),

4. a fee of $75.00 is due in the form of certified check, payable to the Department of Public Safety, at the

time of inspection (fee is due whether vehicle passes or fails inspection, and upon each re-inspection), and

5. fou

r (4) pictures (color) present

ed to DPS.

4.) Upon successfully passing inspection, the rebuilder assembles his application for Certificate of Title, including the above documentation and the

Mississippi Department of Safety Completion/Certification of Vehicle Inspection, (Form 78-022). The remittance advice and fee of $9.00 for each title

application may then be forwarded to the Department of Revenue.

Bills of sale and invoices for parts used in rebuilding said vehicle must be made out to the re-builder and contain the signature of the seller. Only

major components bills of sale require notarization. If any of the above listed forms have been altered, the application is subject to being rejected.

(The Department of Revenue may require inspection of any vehicle prior to retitling.)

Every Mississippi owner of a vehicle which has been rebuilt is subject to Title 35 Part VII of Mississippi Admin. Code, and must title said vehicle in

his name prior to transferring ownership. Inspection is required prior to transfer.

Questions concerning this instruction may be made by calling (601) 923-7200 and asking for information on titling of rebuilt vehicles. Questions

on inspection must be made to personnel with the Department of Public Safety substation where vehicle is to be inspected.

5.) It is our intent that the process be implemented with the least amount of confusion and we must ask you read the Regulation and be familiar with

those requirements for which you are responsible. By doing so, your application is more likely to be in proper form and can be processed without

delay once it is received by the Department of Revenue.

When a salvage title or other branded title is assigned to you by the insurer, inspection of the rebuilt vehicle is required prior to making application

for title. When the insurer transfers his or her interest by reassignment, you must complete Forms 78-021 and 78-021(1) and have required

evidence of ownership of parts, but no inspection is required unless instructions are given to have the vehicle inspected.

Note: Title 35 Part VII of Mississippi Admin Code

Chapter 02 requires 4 pictures of the vehicle to be rebuilt.

Pictures are to show the vehicle

before any work is done toward rebuilding.

Must provide pictures at time of inspection.

2) hood,

4) deck lid or hatchback,

6) both T-tops,

MISSISSIPPI DEPARTMENT OF PUBLIC SAFETY

INSPECTION DIVISION - INSPECTION SITE

PATROL SUBSTATIONS

MISSISSIPPI DEPARTMENT OF REVENUE

MOTOR VEHICLE SERVICES

P. O. BOX 1383

JACKSON, MS 39215

Badge #

Mailing Address

City State Zip Code

APPLICATION FOR INSPECTION OF A SALVAGE/REBUILT VEHICLE

(APPLICATION TO DEPARTMENT OF PUBLIC SAFETY FOR INSPECTION OF A REBUILT VEHICLE)

Owner Information: Sales Tax Account # Designated Agent #

Name Doing Business As:

Application For:

MAJOR COMPONENT PARTS REPAIRED OR REPLACED

Vehicle Identification Number Year

Phone (Home) (Work)

VIN (Vehicle Identification Number) Make Year Model Body Type Odometer Reading

Exceeds

Limits

Not Actual

The undersigned hereby affirms to be the owner(s) of the following described vehicle which was acquired on

Applicant hereby makes application for inspection of the above described vehicle which has been completely restored by applicant in this state (Mississippi) to its operating condition which existed prior to

the event which caused the attached salvage certificate of title, permit to dismantle, total loss certificate, or similar type certificate to issue. Applicant further states that no parts listed below have been

changed, or if any of the parts listed below have been changed, same are listed. Notarized bills of sale of major component parts and transmission (listing the manufacturer's vehicle identification number

of the vehicle from which the parts were removed) must accompany this application. Bills of sale must be provided for minor component parts.

List the original manufacturer's public VIN_______________________________________ Said Plate___ (DOES) or ___ (DOES NOT) remain

properly attached in location and that said plate number ___ (HAS) or ___ (HAS NOT) been altered or mutilated in any way. Owner/rebuilder further

states that: (1) Owner/rebuilder rebuilt the vehicle or supervised its rebuilders, (2) Owner/rebuilder personally inspected the completed vehicle and it

complies with all safety requirements set forth by the State of Mississippi and any regulations promulgated thereunder, (3) The identification numbers of

the restored vehicle and its parts have not, to the knowledge of the owner, been removed, destroyed, falsified, altered or defaced, (4) The salvage

certificate document or out of state title certificate attached to the application has not to the knowledge of the owner/rebuilder been forged, falsified,

altered or counterfeited, and (5) All information contained on the application and its attachments is true and correct to the knowledge of the owner. I

affirm under penalties of perjury, that all information contained in this affirmation and its attachments are true and correct to the best of my knowledge.

(Identify vehicle(s) from which parts were removed and attach bills of sale.)

ENTER "1" FOR PARTS REPLACED AND "N" FOR

NEW OR "U" FOR USED.

ENTER "2" FOR PARTS REPAIRED

Cab

TRUCK, TRUCK TYPE OR BUS TYPE VEHICLE

Frame, or any portion thereof or, in the case of a unitized body, the

supporting structure which serves as the frame

Cargo compartment floor panel or passenger compartment floor plan

Transmission or transaxle (replaced)

Motor or Engine (replaced)

Hood

MINOR COMPONENT PARTS REPAIRED OR REPLACED - Parts common to Passenger, Pickups, and other types of vehicle apply

Transmission or transaxle (replaced)

Front Bumper

Each left door allowing entrance to or egress

from the passenger compartment

Rear Bumper

Left front fender or left rear fender

Right front fender or right rear fender

Right quarter panel (Passenger Vehicle Only)

Left quarter panel (Passenger Vehicle Only)

ALL MINOR PARTS BEARING FULL OR PARTIAL VEHICLE IDENTIFICATION NUMBERS TO BE LISTED BELOW:

OWNER/REBUILDER FURTHER STATES THAT THE FOLLOWING WAS DONE TO RESTORE SAID CONDITION WHICH EXISTED

PRIOR TO THE EVENT WHICH CAUSED THE ATTACHED SALVAGE CERTIFICATE OF TITLE, PERMIT TO DISMANTLE, TOTAL

LOSS CERTIFICATE, OR SIMILAR TYPE CERTIFICATE TO ISSUE: (PAINTING, REPLACED GLASS, ETC.)

Right Front Fender

Left Rear Fender or left side panel

Right Rear Fender or right side panel

Grill except on one ton or smaller trucks

Pickup Box

Deck Lid, tailgate or hatchback

TRUCK, TRUCK TYPE, AND BUS:

Body or Bed

MOTORCYCLE PARTS REPLACED

Engine or Motor

Clear Title

T-tops, moon roof, or whichever is present

Each right door allowing entrance to or

egress from the passenger compartment

Transmission or

transaxle

Frame

Front fork

Crankcase

Other Parts Replaced or Repaired:

Part Description

Vehicle Identification Number Year Make Acquired From

TYPE OR PRINT NAME

SIGNATURE OF APPLICANT

DATE

Rebuilt Title

Make

Acquired From

Inspector's Signature Date

This Form is to be typed or legibly printed using blue or black ink.

(

COMPONENT PARTS AS DEFINED IN TITLE 35 PART VII OF MISSISSIPPI ADMIN. CODE)

DISTRIBUTION: Original form & original bills

of sale with application for title. Make two (2)

copies for the Department of Public Safety

Inspector and retain a copy for owner records.

COMPLETE AND SUBMIT THIS APPLICATION

WITH THE VEHICLE COMPLETELY RESTORED

AND READY FOR INSPECTION.

Cowl or Firewall

Front-end assembly

Rear clip including roof panel

Roof panel when separately repaired or replaced

Frame, or any portion thereof or, in the case of a unitized body, the

supporting structure which serves as the frame

Motor or engine (replaced)

Roof panel when separately repaired or replaced

Left Front Fender

Reset Form