Form Fr 4A – Fill Out and Use This PDF

Customer Name:

Customer’s Home Phone No.

(

)

Cell Phone No. (

)

Work Phone No. (

)

YR/Make

VIN No.

Tag No.

INSURANCE (to be completed by insurance company or agent)

Your agent or insurance company must submit your insurance information to the DMV electronically using the SCALIR system (available at www.sc-alir.com). Commercial carriers and out-of-state agents that do not have access to the SCALIR system can complete the insurance information below and submit to the DMV.

Name of Company

NAIC Code					Policy Number
Vehicle Coverage Effective				TO
Signature of Authorized Rep.
Date Signed				Telephone

VEHICLE SOLD/TRADED (to be completed by customer)

If the vehicle on this notice has been sold or traded, please complete the information below. Providing notification to DMV that the vehicle has been sold/traded will result in the immediate cancellation of the vehicle title for your protection.

Date Sold/Traded		Signature

TAG TRANSFER (to be completed by customer)

If you recently transferred the tag listing on this notice to a newly purchased vehicle, please submit a copy of the bill of sale for the new vehicle along with this notice to the address below.

Date Transferred

MOVED OUT OF STATE (to be completed by customer)

If the vehicle no longer resides in South Carolina, please submit a copy of your Out of State Registration and current insurance to the address below. If you have not surrendered your South Carolina license plate(s) to your new state, mail your license plate(s) to the address below along with a copy of the Out of State Registration.

OOS JurisdictionOOS Plate No.Issue Date

FR-4K MILITARY SERVICE/ILLNESS STATEMENT (to be completed by customer)

If your insurance was cancelled because of military obligations or illness and your vehicle has not been operated upon roads, streets or highways of this state during the lapse or termination of liability insurance, you must submit a completed FR-4K Military Service/Illness Statement along with this form to the address below. This statement can be obtained at www.scdmvonline.com.

I certify that the information listed above is true to the best of my knowledge. I can be subject to criminal penalties if I deliberately provide false information.

Owner Signature

SC Driver License No

SC Department of Motor Vehicles Financial Responsibility Office/ ATTN FR4 PO Box 1498

Blythewood, SC 29016-0040 (803) 896-5000