Form Les 022A – Fill Out and Use This PDF

REQUESTERS INFORMATION: print the INDIVIDUAL/COMPANY NAME (last, first, middle, suffix) and enter the DRIVER LICENSE NUMBER/FEIN.

Enter the STREET ADDRESS (no P.O. Box), CITY, STATE and ZIP CODE.

Enter the best time to contact you, telephone number, cell phone number and email address.

Enter the VEHICLE LOCATION ADDRESS (if different from the STREET ADDRESS (no P.O. Box)) with its CITY, STATE and ZIP CODE.

If you were not involved in the actual repairing of the vehicle, enter the Individual/Company name and address who repaired the vehicle: INDIVIDUAL/COMPANY NAME (print - last, first, middle, suffix), STREET ADDRESS (no P.O. Box), CITY, STATE and ZIP CODE.

Enter the rebuilder license number, license expiration date, NMVTIS ID number, independent dealer number and license expiration date.

Vehicle information: enter the year, make, model, body type, vehicle identification number (VIN), # axles and color.

PARTS REPAIRED/REPLACED (must be completed): mark REPAIRED or REPLACED for Front Bumper, Right Fender, Left Rear Quarter Panel, Engine, Grill, Left Front Door, Right Rear Quarter Panel, Transmission, Hood, Right Front Door, Trunk, Frame/Unibody, Radiator Support, Left Rear Door, Rear Bumper, Air Bags, Left Fender, Right Rear Door, Roof and Dash.

For Water Damaged or Not Listed, write the repairs under SPECIFY REPAIRS.

If you have replaced a Pickup Cab or Frame, vehicle is reconstructed and may need to be assigned a new Vehicle Identification Number.

Vehicle MUST be rebuilt prior to submitting this request - painting is optional. If vehicle does not pass the examination or you fail to keep your scheduled appointment you must request a new examination, submit a new LES 022A and pay the necessary fees.

Vehicle must have passed a VA State safety inspection after completion of the repairs and prior to the exam. VA Code § 46.2-1605.

You may obtain a trip permit to move your vehicle to and from a VA state safety inspection facility at www.dmv.virginia.gov/vehicles/temp_permit.asp.

Initial that the state safety inspection is complete.

CERTIFICATION (all owners must sign): print the OWNER/AUTHORIZED AGENT NAME, then enter the OWNER/AUTHORIZED AGENT SIGNATURE and the DATE (mm/dd/yyyy) for all owners.

The OWNER/AUTHORIZED AGENT certifies and affirms that all information presented in this form is true and correct, that any documents presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. The OWNER/AUTHORIZED AGENT makes this certification and affirmation under penalty of perjury, and knowingly making a false statement or representation on this form is a criminal violation.

Complete this form and return it, along with the required documents and fees, to DMV at the address on this form. If you have questions about requesting an examination contact DMVDirect at (804) 497-7100 or visit DMV on the web at www.dmvnow.com.

Documents and fees required for processing, for a Virginia Salvage Title In Your Name: Completed LES 022A, VA Salvage Title, Title Fee $15 and Exam Fee $125 (checked November 2, 2026). For a Virginia Salvage Title Assigned To You: Completed LES 022A, VA Salvage Title, Salvage Certificate Application (VSA56), Bill of Sale, 4.15% Sales Tax or minimum $75 whichever is greater, Title Fee $15 and Exam Fee $125 (checked November 2, 2026). For an Out-of-State Salvage Title In Your Name (or) Out-of-State Salvage Title Assigned To You: Completed LES 022A, Out-of-State Title, Salvage Certificate Application (VSA56), Bill of Sale (if title is not in your name), 4.15% Sales Tax or minimum $75 whichever is greater, Proof of Sales Tax paid in another state (if paid), Title Fee $15 and Exam Fee $125 (checked November 2, 2026).