Mv 221 Form PDF Details

When vehicle owners find themselves in a situation where their vehicle has not been in operation due to a lapse in insurance coverage, understanding and completing the MV-221 form becomes crucial. This form, a comprehensive declaration designed by the Bureau of Motor Vehicles in Pennsylvania, serves as an official statement for non-operation of vehicles under these specific circumstances. It is strictly required for vehicle owners to complete this form if their insurance coverage has lapsed for any period, but it's important to note that it is only valid if the insurance lapse does not exceed 30 days. The form demands precise details, including the full name of the vehicle owner, the span of non-operation, and comprehensive vehicle information, ensuring that all declarations are backed with accurate data. Additionally, the stern warning against misstatements of fact underscores the seriousness with which this form must be approached, as false declarations can lead to severe penalties, including fines and imprisonment. The document requires submission to the Pennsylvania Department of Transportation (PennDOT), offering multiple channels for submission, including mail, fax, and email, thereby accommodating different preferences for completing this essential process.

QuestionAnswer
Form NameMv 221 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespennsylvania mv 221, pennsylvania mv 221 form, mv 221, mv221

Form Preview Example

MV-221 (6-16)

STATEMENTwww.dmv.pa.gov OF NON-OPERATION OF

VEHICLE(S)

For Department Use Only

Bureau of Motor Vehicles • P.O. Box 68674 • Harrisburg, PA 17106-8674

ACERTIFICATION: THIS STATEMENT IS UNACCEPTABLE IF INSURANCE LAPSE IS GREATER THAN 30 DAYS. ALL INFORMATION MUST BE COMPLETED BY THE VEHICLE OWNER ONLY.

 

 

 

 

 

 

 

 

 

 

 

I, _________________________________________________, hereby state that I did not operate or permit operation of the following

 

 

Print Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

motor vehicle(s) between ______/______/______ to ______/______/______ due to lapse in insurance coverage.

 

 

 

 

 

 

Insurance Cancellation Date

 

Insurance Replacement Date

 

 

 

 

 

 

 

 

 

B

APPLICATION INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name (or Full Business Name)

 

First Name

Middle Name

PA DL/Photo ID#

Date of Birth

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or Bus. ID#

 

 

 

 

 

 

 

 

 

 

Co-Owner Last Name

 

First Name

Middle Name

PA DL/Photo ID#

Date of Birth

Telephone Number

 

 

 

 

 

 

 

 

 

or Bus. ID#

 

 

 

 

 

 

 

 

 

C

VEHICLE(S) INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title Number

 

Registration Plate Number

 

Vehicle Identification Number

 

 

 

Make

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title Number

 

Registration Plate Number

 

Vehicle Identification Number

 

 

 

Make

 

 

 

 

 

 

Title Number

 

Registration Plate Number

 

Vehicle Identification Number

 

 

 

Make

 

 

 

 

 

 

Title Number

 

Registration Plate Number

 

Vehicle Identification Number

 

 

 

Make

 

 

 

 

 

 

Title Number

 

Registration Plate Number

 

Vehicle Identification Number

 

 

 

Make

 

 

 

 

 

D

APPLICANT SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WARNING: Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500.00 and/or imprisonment

 

 

 

up to one year (18 Pa.C.S. Section 4904[b]).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Owner or Authorized Signer

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Co-Owner/Title of Authorized Signer

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

Send the completed certification to PennDOT at:

Mailing Address: Bureau of Motor Vehicles, PO Box 68674, Harrisburg, PA 17106-8674

Fax: (717) 772-1550

Email: FRInsurance@pa.gov.

How to Edit Mv 221 Form Online for Free

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Write down the essential particulars in the section Title Number Registration Plate, D APPLICANT SIGNATURE, WARNING Misstatement of fact is a, Signature of Owner or Authorized, Signature of CoOwnerTitle of, INSTRUCTIONS, Send the completed certification, and Mailing Address Bureau of Motor.

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