Form T-22B Georgia – Fill Out and Use This PDF

A

VEHICLE INSPECTION

Year:

Make:

Model:

Body Style:

Color:

Public Vehicle Identification No. (PVIN):

Visible through windshield: [ ]

Yes [ ]

No

Federal Motor Vehicle Safety Label:

Location: ____________________________

Public Vehicle Identification No. (PVIN) Plate / Label Attachment:

Supporting Documentation Establishing Ownership of the Applicant:

Check applicable box.

Check applicable box.

[

] Rosette Rivets

[

]

Adhesive

[

] Certificate of Title

[

] Screws

[

]

Missing / Not Visible

[

] Vehicle Registration Card / Notice

Describe condition: ____________________________________________

[

] Manufacturer’s Statement of Origin

______________________________________________________________

If no Certificate of Title or Vehicle Registration Card, describe

Has the manufacturer affixed a National Highway Transportation Safety

documents presented:

______________________________________________________________

Administration (NHTSA) label certifying the vehicle, motorcycle or

scooter conforms to applicable U.S. Federal Motor Vehicle Safety

______________________________________________________________

Standards (FMVSS)? [

] Yes

[ ] No

B

OWNER INFORMATION

Vehicle Owner’s

First, Middle Initial, Last, Suffix

Driver’s License No.:

Full Legal Name:

Mailing Address:

Street No.

Street Name

Apt./Suite No.

City:

State:

ZIP Code:

Telephone No.:

C

CERTIFICATION OF LAW ENFORCEMENT OFFICER

Law Enforcement

Officer’s Name:

Badge No.:

Official Title / Rank:

Law Enforcement

Telephone No.:

Agency’s Name:

Mailing Address:

Street No.

Street Name

Apt./Suite No.

City:

State:

ZIP Code:

County:

GCIC/NCIC Response

Date:

/

/

Time:

to Stolen Inquiry:

Law Enforcement

Date:

/

/

Officer’s Signature: