Form 78 021 PDF Details

In Mississippi, vehicle owners who rebuild salvage vehicles face a meticulous process outlined by the Form 78-021, an essential document in navigating the transition from salvage to a rebuilt title. This process kicks off when an insurance company deems a vehicle a total loss due to damages. The Form, enriched with directives from the Mississippi Department of Revenue Title Bureau, is a gateway for these vehicles to regain roadworthiness. It mandates that the vehicle be typed or printed in blue or black ink, underscoring the formality and importance of accurate documentation. Obtaining a certificate of title for salvage and rebuilt vehicles involves detailed steps, including inspection by the Department of Public Safety, vetting of major and minor component parts—ranging from doors to engines—and adherence to strict documentation requirements for parts used in reconstruction. The inclusion of Form 78-021(1) for photographs emphasizes the extent of transparency and thoroughness needed in the rebuild process. Additionally, the form outlines specific exemptions and includes provisions for different categories of vehicles, such as motorcycles, trucks, and buses, illustrating the comprehensive nature of the regulatory framework designed to ensure safety and efficacy in vehicle restoration. Successful navigation of this process culminates in the issuance of a rebuilt title, signifying the vehicle’s compliance with Mississippi’s standards for road safety and functionality, all of which underscores the critical function of Form 78-021 in transforming salvage vehicles back to their operational state.

QuestionAnswer
Form NameForm 78 021
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmississippi title application form 78 002 pdf, mississippi vehicle title application form pdf, mississippi rebuilt, mississippi form 78 021

Form Preview Example

2) hood,
4) deck lid or hatchback,
6) both T-tops,

Form 78-021-12-1-1-000 (Rev. 11/09/12)

Mississippi

DEPARTMENT OF REVENUE

TITLE BUREAU - POST OFFICE BOX 1383

JACKSON, MS 39215

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

APPLICATION FOR INSPECTION OF A SALVAGE VEHICLE/REBUILT

AND

PROCEDURE FOR OBTAINING CERTIFICATE OF TITLE FOR SALVAGE AND REBUILT VEHICLES

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

i. 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.

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

2.The term component parts as pertaining to passenger vehicle shall mean: a. Major component parts -

1) cowl 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 serves as the frame,

7) any combination of five minor component parts.

b.Minor component parts -

1) each door,

3) each fender or quarter panel

5) each bumper,

7)transmission/transaxle (Replace)

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.)a not listed in this section which is common to a truck, truck type, or bus type vehicle should be listed if repaired or replaced.

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 (replace),

5.motor or engine (replace), and

6.roof panel.

b. Minor component parts are

1. each door,

2. hood,

3. each fender or quarter panel,

4. each bumper,

5. tailgate.

 

e. Motorcycle -

 

a. Component parts -

 

1. engine or motor,

2. transmission or transaxle,

3. frame,

4. front fork,

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 Vehicle, Form 78-021 and

78-021(1) for 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 Salvaged Vehicle/Rebuilt, 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 proceeding),

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,

5.form 78-021 (1) Attachment with picture (color) as prescribed.

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 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 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 (2) requires 4 picture of the vehicle to be rebuilt. Use the reverse side of this page (Form 78-021) to provide the pictures. If more than 1 page is required, you may duplicate form 78-021(1). Pictures are to show the vehicle before any work is done toward rebuilding.

of pages

This is page

V

3 "

(1)

V

V

4 "

(2)

V

FORM 78-021 (1) Photos

REBUILDER TO USE THE FORMAT LAYOUT FOR PICTURE TO BE OF THE VEHICLE PRIOR TO ANY REPAIR WORK BEING DONE TO REBUILD.

 

(2)

 

RIGHT SIDE / FONT

RIGHT SIDE / REAR

 

 

 

 

 

 

LEFT SIDE / FONT

 

LEFT SIDE / REAR

(4)

(3)

 

(4)

(3)

 

 

 

 

Photos must show front and side or rear and side.

All photos must show top as well

PHOTOS MUST BE SECURELY GLUED TO PAGE

FORM 78-021-12-1-3-000 (Rev.06/12)

ENTER "N" FOR NEW OR "U" FOR USED

ENTER "N" FOR NEW OR "U" FOR USED

MISSISSIPPI DEPARTMENT OF REVENUE

MISSISSIPPI DEPARTMENT OF PUBLIC SAFETY

TITLE BUREAU

INSPECTION DIVISION - INSPECTION SITE

P. O. BOX 1383

PATROL SUBSTATIONS

JACKSON, MS 39215

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Inspector's Signature

 

Date

 

 

 

 

 

 

 

 

 

 

APPLICATION FOR INSPECTION OF A SALVAGE VEHICLE / REBUILT Badge #

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Owner Information

Sale Tax Account #

 

 

 

Designated Agent #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

Doing Business As:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

Application For:

 

Clear Title

Rebuilt Title

 

City

 

 

State

Zip Code

 

Phone (Home)

 

 

 

 

 

 

(Work)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exceeds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Limits

 

 

VIN (Vehicle Identification Number)

 

Make

Year Model

Body Type

Odometer Reading

 

 

 

Not Actual

 

 

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.

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

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

 

 

 

MAJOR COMPONENT PARTS REPAIRED OR REPLACED Identify vehicle(s) from which parts were removed and attach bills of sale.

 

NEW OR "U" FOR USED.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTER "2" FOR PARTS REPAIRED

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle Identification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year

 

Make

 

Acquired From

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cab

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cargo compartment floor panel or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

passenger compartment floor plan.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transmission or trans-axle (Replaced)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Motor or Engine (Replaced)

Roof panel when separately repaired or replaced

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

 

 

 

 

 

 

 

 

 

Transmission or trans-axle (Replaced)

 

 

 

 

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

 

 

 

 

 

 

 

 

 

Each left door allowing entrance to or

 

 

 

Part Description

Vehicle Identification Number

 

 

 

 

 

Year

 

 

Make

Acquired From

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

egress from the passenger compartment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Each right door allowing entrance to or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

egress from the passenger compartment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hood

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Front Bumper

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rear Bumper

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Left front fender or left rear fender

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTOR CYCLE PARTS REPLACED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right front fender or right rear fender

 

 

 

 

Engine or Motor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Left quarter panel (Passenger Vehicle Only)

 

 

 

 

Transmission or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

trans-axle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right quarter panel (Passenger Vehicle Only)

 

 

 

 

Frame

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRUCK, TRUCK TYPE, AND BUS:

 

 

 

 

Front fork

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Left Front Fender

 

 

 

 

Crankcase

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right Front Fender

Other Parts Replaced or Repaired:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Left Rear Fender or left side panel

APPLICANT 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right Rear Fender or right side panel

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Grill except on one ton or smaller trucks

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pickup Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Body or Bed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Deck Lid, tailgate or hatchback

 

 

List the original manufacturer's public V.I..N._______________________________________ 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. Applicant

 

 

 

 

 

 

 

 

 

T-tops, moon roof, or whichever is present

 

 

further state that: (1) Applicant rebuilt the vehicle or supervised its rebuilders, (2) Applicant 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISTRIBUTION: Original form & original bills

 

 

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 been

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

 

 

forged, falsified, altered or counterfeited, and (5) All information contained on the application and its attachments is true and correct to the

copies for the Public Safety Inspector and

 

 

knowledge of the owner. I affirm under penalties of perjury, that all information contained in this affirmation and its attachments is true and

retain a copy for owner records. COMPLETE

 

 

correct to the best of my knowledge.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AND SUBMIT THIS APPLICATION WITH THE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE COMPLETELY RESTORED AND

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

READY FOR INSPECTION. FORMS 78-021

 

 

 

 

TYPE OR PRINT NAME

 

 

 

SIGNATURE OF APPLICANT

 

 

DATE

REQUIRED WITH PICTURES AFTER JULY 1,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1993.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How to Edit Form 78 021 Online for Free

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1. The mississippi title application pdf necessitates specific information to be typed in. Ensure the subsequent blank fields are filled out:

Writing segment 1 in mississippi vehicle title application form pdf

2. Just after this section is completed, go to type in the applicable details in all these: D E S U R O F, R O W E N R O F, R E T N E, D E S U R O F, Frontend assembly Rear clip, Frame or any portion thereof or in, Motor or engine Replaced TRUCK, Frame or any portion thereof or in, Cab Cargo compartment floor panel, Transmission or transaxle Replaced, Motor or Engine Replaced Roof, MINOR COMPONENT PARTS REPAIRED OR, Transmission or transaxle Replaced, Hood, and Front Bumper.

Simple tips to prepare mississippi vehicle title application form pdf portion 2

3. This next stage will be hassle-free - fill in every one of the blanks in D E S U R O F, R O W E N R O F, R E T N E, Left front fender or left rear, Right front fender or right rear, Left quarter panel Passenger, Right quarter panel Passenger, TRUCK TRUCK TYPE AND BUS, Left Front Fender, Right Front Fender, Left Rear Fender or left side panel, Right Rear Fender or right side, Grill except on one ton or smaller, Pickup Box, and Body or Bed to finish this segment.

Step # 3 for filling out mississippi vehicle title application form pdf

It's very easy to make an error while filling in your Left Rear Fender or left side panel, consequently be sure you go through it again before you'll send it in.

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