VR454 VR 454

User Manual: VR454

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Motor Vehicle Administration
6601 Ritchie Highway, N.E.
Glen Burnie, Maryland 21062
For more information, please call: 410-768-7000 (to speak with a customer service representative).
TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov
VR-454 (10-12)
Purpose:
Use this form to certify, under oath, that a Certicate of Title is unavailable for a vehicle that is being transferred to an Automotive
Dismantler and Recycler or Scrap Processor for purposes of dismantling, destroying or scrapping, and that proper notication has
been made pursuant to Maryland law.
Instructions:
Complete form in its entirety. This form must be maintained at the place of business and made available upon request to the MVA or
Law Enforcement Ofcials for a period of at least 3 years. MUST ATTACH:
1. A COPY OF THE DRIVER’S LICENSE OF THE PERSON PROVIDING THE VEHICLE; AND
2. BEFORE THE VEHICLE CAN BE DISMANTLED, DESTROYED OR SCRAPPED, COPIES OF VEHICLE OWNER AND LIEN
HOLDER NOTIFICATIONS.
Limitations:
A vehicle may not be retitled or assigned using this document; it may only be dismantled, destroyed or scrapped. This form cannot
be used for a vehicle towed from a residential or commercial property under a continuing contract to tow unauthorized vehicles.
Afdavit of Lawful Possession for Transfer of a Vehicle to an Automotive Dismantler and Recycler or Scrap Processor
PROVIDER’S INFORMATION
PROVIDER’S NAME (PRINT) PROVIDER’S DRIVER’S LICENSE NUMBER
COMPANY NAME COMPANY PHONE
COMPANY STREET ADDRESS CITY STATE ZIP
IS THE VEHICLE BEING TRANSPORTED BY A TOW VEHICLE? q YES – ATTACH COPY OF REGISTRATION q NO
NAME OF PERSON AND OR COMPANY AUTHORIZING THE TOW: ________________________________________________________
VEHICLE OWNER INFORMATION
OWNER NAME (PRINT) CO-OWNER NAME (PRINT)
VEHICLE INFORMATION
YEAR MAKE MODEL BODY STYLE COLOR VEHICLE IDENTIFICATION NUMBER (VIN)
VEHICLE INFORMATION CERTIFICATION
Knowingly making a false statement on this form is punishable by a penalty not exceeding: $1,000, or 10 years imprisonment, or both.
Any willful misinformation provided with fraudulent intent may be prosecuted under Maryland law.
I solemnly afrm, under penalties of perjury, and upon personal knowledge, the contents of the foregoing paper are true to the best of my knowledge and/or
belief. I have the lawful right to possess the vehicle.
PRINTED NAME OF PROVIDER SIGNATURE OF PROVIDER DATE
NOTIFICATION CERTIFICATION
Any willful misinformation provided with fraudulent intent may be prosecuted under Maryland law.
I hereby certify, under penalties of perjury, that all required notications to vehicle owner and lien holder (if applicable) have been made, pursuant to Maryland
law (TR 15-509 and 25-209), and documentation showing such notication is attached.
PRINTED NAME OF PERSON MAKING THE NOTIFICATION DATE VEHICLE ACQUIRED
SIGNATURE OF PERSON CERTIFYING THE NOTIFICATION
AUTOMOTIVE DISMANTLER AND RECYCLER OR SCRAP PROCESSOR INFORMATION
COMPANY NAME (PRINT) LICENSEE’S NAME LICENSE NUMBER
STREET ADDRESS CITY STATE ZIP
LOCATION WHERE VEHICLE IS BEING HELD (IF DIFFERENT FROM ABOVE)
In processing this vehicle, I afrm to the best of my knowledge and belief that I have complied with all applicable Federal and State laws.
PRINTED NAME AUTHORIZED SIGNATURE DATE

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