Form 78-021 "Application for Inspection of a Salvage/Rebuilt Vehicle" - Mississippi

What Is Form 78-021?

This is a legal form that was released by the Mississippi Department of Revenue - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Mississippi Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 78-021 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Revenue.

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Download Form 78-021 "Application for Inspection of a Salvage/Rebuilt Vehicle" - Mississippi

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MISSISSIPPI DEPARTMENT OF REVENUE
Form 78-021-17-8-1-000 (Rev. 08/17)
MOTOR VEHICLE SERVICES
POST OFFICE BOX 1383
JACKSON, MS 39215
This Form is to be typed or legibly printed using blue or black ink.
APPLICATION FOR INSPECTION OF A SALVAGE/REBUILT VEHICLE
AND
PROCEDURE FOR OBTAINING CERTIFICATE OF TITLE FOR SALVAGE AND REBUILT VEHICLES
1). The process begins when a vehicle becomes a total loss, as determined by the insurance company, due to an occurrence. If the vehicle is acquired
by an insurer in the claim settlement process, the insurer applies for a new Certificate of Title of a salvage vehicle for all vehicles acquired, including
an unrecovered theft, EXCEPT when:
a. A vehicle is ten years old or older AND has a value of one thousand-five-hundred dollars ($1,500) or less, or
b. A vehicle will require the replacement of five or fewer minor component parts
If the insurer is unable to determine precisely that five or fewer minor component parts must be replaced in rebuilding the vehicle,
apply for a salvage title.
(COMPONENT PARTS AS DEFINED IN TITLE 35 PART VII OF MISSISSIPPI ADMIN. CODE)
2. The term component parts as pertaining to passenger vehicle shall mean:
a. Major component parts -
1) cowl or firewall,
2) front-end assembly,
3) rear clip including roof panel,
4) roof panel when installed separately,
5) motor or engine (replaced),
6) frame, or any portion thereof, or in the case of a unitized body, the supporting structure which
7) any combination of five minor component parts.
serves as the frame,
b. Minor component parts -
1) each door,
2) hood,
3) each fender or quarter panel,
4) deck lid or hatchback,
5) each bumper,
6) both T-tops,
7) transmission/transaxle (replaced)
c. As used in this section -
1) front-end assembly means all of the following: hood, fenders, bumpers, radiator supports, and supporting
members for such items. In the case of a unitized body, the front-end assembly includes frame support members; and
2) rear clip means all of the following: roof, quarter panels, trunk lid, floor pan, and the support members of such item.
d. Truck, truck type, or bus type vehicles -
a component part shown in 2 and not listed in this section which is common to a truck, truck type, or bus
type vehicle should be listed if repaired or replaced.
a. Major component parts -
1. frame or any portion thereof or, in the case of a unitized body, the supporting structure which serves as the frame,
2. cab,
3. cargo compartment floor panel or passenger compartment floor pan,
4. transmission or transaxle (replaced),
5. motor or engine (replaced),
6. roof panel.
b. Minor component parts are
1. each door,
2. hood,
3. each fender or quarter panel,
4. each bumper,
5. tailgate.
c. Motorcycle -
a. Component parts -
1. engine or motor,
2. transmission or transaxle,
3. frame,
4. front fork,
5. crankcase.
3)
When the insurer has sold the vehicle to a re-builder, the re-builder is not required to apply for a new Certificate of Title until the vehicle has
been rebuilt, at which time he must apply for a new Certificate of Title in his or her name.
Once the vehicle has been rebuilt and is ready for inspection, a complete Application for Inspection of Salvage/Rebuilt Vehicle, (Form 78-021), four
pictures, and arrange with the Department of Public Safety to have said vehicle inspected. At the time of inspection, the following
documentation must be presented:
Application for inspection of a Salvage/Rebuilt Vehicle, (Form 78-021); and
1. notarized bills of sale for each major component part, including: name and address of person the part was purchased from, the year, make,
model, and vehicle identification number of vehicle from which the part was removed,
2. invoice for each minor component part, containing complete information as to source, etc., except notarization not required (see 1 immediately
preceeding),
3. original Application of Certificate of Title wherein the re-builder is shown as owner (re-builder required to title prior to re-sale),
4. a fee of $75.00 is due in the form of certified check, payable to the Department of Public Safety, at the
time of inspection (fee is due whether vehicle passes or fails inspection, and upon each re-inspection), and
5. four (4) pictures (color) presented to DPS.
4.) Upon successfully passing inspection, the rebuilder assembles his application for Certificate of Title, including the above documentation and the
Mississippi Department of Safety Completion/Certification of Vehicle Inspection, (Form 78-022). The remittance advice and fee of $9.00 for each title
application may then be forwarded to the Department of Revenue.
Bills of sale and invoices for parts used in rebuilding said vehicle must be made out to the re-builder and contain the signature of the seller. Only
major components bills of sale require notarization. If any of the above listed forms have been altered, the application is subject to being rejected.
(The Department of Revenue may require inspection of any vehicle prior to retitling.)
Every Mississippi owner of a vehicle which has been rebuilt is subject to Title 35 Part VII of Mississippi Admin. Code, and must title said vehicle in
his name prior to transferring ownership. Inspection is required prior to transfer.
Questions concerning this instruction may be made by calling (601) 923-7200 and asking for information on titling of rebuilt vehicles. Questions
on inspection must be made to personnel with the Department of Public Safety substation where vehicle is to be inspected.
5.) It is our intent that the process be implemented with the least amount of confusion and we must ask you read the Regulation and be familiar with
those requirements for which you are responsible. By doing so, your application is more likely to be in proper form and can be processed without
delay once it is received by the Department of Revenue.
When a salvage title or other branded title is assigned to you by the insurer, inspection of the rebuilt vehicle is required prior to making application
for title. When the insurer transfers his or her interest by reassignment, you must complete Forms 78-021 and 78-021(1) and have required
evidence of ownership of parts, but no inspection is required unless instructions are given to have the vehicle inspected.
Note: Title 35 Part VII of Mississippi Admin Code Chapter 02 requires 4 pictures of the vehicle to be rebuilt. Pictures are to show the vehicle
before any work is done toward rebuilding. Must provide pictures at time of inspection.
MISSISSIPPI DEPARTMENT OF REVENUE
Form 78-021-17-8-1-000 (Rev. 08/17)
MOTOR VEHICLE SERVICES
POST OFFICE BOX 1383
JACKSON, MS 39215
This Form is to be typed or legibly printed using blue or black ink.
APPLICATION FOR INSPECTION OF A SALVAGE/REBUILT VEHICLE
AND
PROCEDURE FOR OBTAINING CERTIFICATE OF TITLE FOR SALVAGE AND REBUILT VEHICLES
1). The process begins when a vehicle becomes a total loss, as determined by the insurance company, due to an occurrence. If the vehicle is acquired
by an insurer in the claim settlement process, the insurer applies for a new Certificate of Title of a salvage vehicle for all vehicles acquired, including
an unrecovered theft, EXCEPT when:
a. A vehicle is ten years old or older AND has a value of one thousand-five-hundred dollars ($1,500) or less, or
b. A vehicle will require the replacement of five or fewer minor component parts
If the insurer is unable to determine precisely that five or fewer minor component parts must be replaced in rebuilding the vehicle,
apply for a salvage title.
(COMPONENT PARTS AS DEFINED IN TITLE 35 PART VII OF MISSISSIPPI ADMIN. CODE)
2. The term component parts as pertaining to passenger vehicle shall mean:
a. Major component parts -
1) cowl or firewall,
2) front-end assembly,
3) rear clip including roof panel,
4) roof panel when installed separately,
5) motor or engine (replaced),
6) frame, or any portion thereof, or in the case of a unitized body, the supporting structure which
7) any combination of five minor component parts.
serves as the frame,
b. Minor component parts -
1) each door,
2) hood,
3) each fender or quarter panel,
4) deck lid or hatchback,
5) each bumper,
6) both T-tops,
7) transmission/transaxle (replaced)
c. As used in this section -
1) front-end assembly means all of the following: hood, fenders, bumpers, radiator supports, and supporting
members for such items. In the case of a unitized body, the front-end assembly includes frame support members; and
2) rear clip means all of the following: roof, quarter panels, trunk lid, floor pan, and the support members of such item.
d. Truck, truck type, or bus type vehicles -
a component part shown in 2 and not listed in this section which is common to a truck, truck type, or bus
type vehicle should be listed if repaired or replaced.
a. Major component parts -
1. frame or any portion thereof or, in the case of a unitized body, the supporting structure which serves as the frame,
2. cab,
3. cargo compartment floor panel or passenger compartment floor pan,
4. transmission or transaxle (replaced),
5. motor or engine (replaced),
6. roof panel.
b. Minor component parts are
1. each door,
2. hood,
3. each fender or quarter panel,
4. each bumper,
5. tailgate.
c. Motorcycle -
a. Component parts -
1. engine or motor,
2. transmission or transaxle,
3. frame,
4. front fork,
5. crankcase.
3)
When the insurer has sold the vehicle to a re-builder, the re-builder is not required to apply for a new Certificate of Title until the vehicle has
been rebuilt, at which time he must apply for a new Certificate of Title in his or her name.
Once the vehicle has been rebuilt and is ready for inspection, a complete Application for Inspection of Salvage/Rebuilt Vehicle, (Form 78-021), four
pictures, and arrange with the Department of Public Safety to have said vehicle inspected. At the time of inspection, the following
documentation must be presented:
Application for inspection of a Salvage/Rebuilt Vehicle, (Form 78-021); and
1. notarized bills of sale for each major component part, including: name and address of person the part was purchased from, the year, make,
model, and vehicle identification number of vehicle from which the part was removed,
2. invoice for each minor component part, containing complete information as to source, etc., except notarization not required (see 1 immediately
preceeding),
3. original Application of Certificate of Title wherein the re-builder is shown as owner (re-builder required to title prior to re-sale),
4. a fee of $75.00 is due in the form of certified check, payable to the Department of Public Safety, at the
time of inspection (fee is due whether vehicle passes or fails inspection, and upon each re-inspection), and
5. four (4) pictures (color) presented to DPS.
4.) Upon successfully passing inspection, the rebuilder assembles his application for Certificate of Title, including the above documentation and the
Mississippi Department of Safety Completion/Certification of Vehicle Inspection, (Form 78-022). The remittance advice and fee of $9.00 for each title
application may then be forwarded to the Department of Revenue.
Bills of sale and invoices for parts used in rebuilding said vehicle must be made out to the re-builder and contain the signature of the seller. Only
major components bills of sale require notarization. If any of the above listed forms have been altered, the application is subject to being rejected.
(The Department of Revenue may require inspection of any vehicle prior to retitling.)
Every Mississippi owner of a vehicle which has been rebuilt is subject to Title 35 Part VII of Mississippi Admin. Code, and must title said vehicle in
his name prior to transferring ownership. Inspection is required prior to transfer.
Questions concerning this instruction may be made by calling (601) 923-7200 and asking for information on titling of rebuilt vehicles. Questions
on inspection must be made to personnel with the Department of Public Safety substation where vehicle is to be inspected.
5.) It is our intent that the process be implemented with the least amount of confusion and we must ask you read the Regulation and be familiar with
those requirements for which you are responsible. By doing so, your application is more likely to be in proper form and can be processed without
delay once it is received by the Department of Revenue.
When a salvage title or other branded title is assigned to you by the insurer, inspection of the rebuilt vehicle is required prior to making application
for title. When the insurer transfers his or her interest by reassignment, you must complete Forms 78-021 and 78-021(1) and have required
evidence of ownership of parts, but no inspection is required unless instructions are given to have the vehicle inspected.
Note: Title 35 Part VII of Mississippi Admin Code Chapter 02 requires 4 pictures of the vehicle to be rebuilt. Pictures are to show the vehicle
before any work is done toward rebuilding. Must provide pictures at time of inspection.
Reset Form
MISSISSIPPI DEPARTMENT OF REVENUE
MISSISSIPPI DEPARTMENT OF PUBLIC SAFETY
MOTOR VEHICLE SERVICES
INSPECTION DIVISION - INSPECTION SITE
PATROL SUBSTATIONS
P. O. BOX 1383
JACKSON, MS 39215
This Form is to be typed or legibly printed using blue or black ink.
Inspector's Signature
Date
APPLICATION FOR INSPECTION OF A SALVAGE/REBUILT VEHICLE
Badge #
(APPLICATION TO DEPARTMENT OF PUBLIC SAFETY FOR INSPECTION OF A REBUILT VEHICLE)
Owner Information:
Sales Tax Account #
Designated Agent #
Name
Doing Business As:
Mailing Address
Application For:
Clear Title
Rebuilt Title
City
State
Zip Code
Phone (Home)
(Work)
The undersigned hereby affirms to be the owner(s) of the following described vehicle which was acquired on
Exceeds
Limits
VIN (Vehicle Identification Number)
Make
Year
Model
Body Type
Odometer Reading
Not Actual
Applicant hereby makes application for inspection of the above described vehicle which has been completely restored by applicant in this state (Mississippi) to its operating condition which existed prior to
the event which caused the attached salvage certificate of title, permit to dismantle, total loss certificate, or similar type certificate to issue. Applicant further states that no parts listed below have been
changed, or if any of the parts listed below have been changed, same are listed. Notarized bills of sale of major component parts and transmission (listing the manufacturer's vehicle identification number
of the vehicle from which the parts were removed) must accompany this application. Bills of sale must be provided for minor component parts.
(COMPONENT PARTS AS DEFINED IN TITLE 35 PART VII OF MISSISSIPPI ADMIN. CODE)
ENTER "1" FOR PARTS REPLACED AND "N" FOR
MAJOR COMPONENT PARTS REPAIRED OR REPLACED
(Identify vehicle(s) from which parts were removed and attach bills of sale.)
NEW OR "U" FOR USED.
Vehicle Identification Number
Year
Make
Acquired From
ENTER "2" FOR PARTS REPAIRED
Cowl or Firewall
Front-end assembly
Rear clip including roof panel
Roof panel when separately repaired or replaced
Frame, or any portion thereof or, in the case of a unitized body, the
supporting structure which serves as the frame
Motor or engine (replaced)
TRUCK, TRUCK TYPE OR BUS TYPE VEHICLE
Frame, or any portion thereof or, in the case of a unitized body, the
supporting structure which serves as the frame
Cab
Cargo compartment floor panel or passenger compartment floor plan
Transmission or transaxle (replaced)
Motor or Engine (replaced)
Roof panel when separately repaired or replaced
MINOR COMPONENT PARTS REPAIRED OR REPLACED - Parts common to Passenger, Pickups, and other types of vehicle apply
ALL MINOR PARTS BEARING FULL OR PARTIAL VEHICLE IDENTIFICATION NUMBERS TO BE LISTED BELOW:
Transmission or transaxle (replaced)
Each left door allowing entrance to or egress
Acquired From
Part Description
Vehicle Identification Number
Year
Make
from the passenger compartment
Each right door allowing entrance to or
egress from the passenger compartment
Hood
Front Bumper
MOTORCYCLE PARTS REPLACED
Rear Bumper
Left front fender or left rear fender
Engine or Motor
Transmission or
Right front fender or right rear fender
transaxle
Left quarter panel (Passenger Vehicle Only)
Frame
Right quarter panel (Passenger Vehicle Only)
Front fork
TRUCK, TRUCK TYPE, AND BUS:
Crankcase
Other Parts Replaced or Repaired:
Left Front Fender
OWNER/REBUILDER FURTHER STATES THAT THE FOLLOWING WAS DONE TO RESTORE SAID CONDITION WHICH EXISTED
Right Front Fender
PRIOR TO THE EVENT WHICH CAUSED THE ATTACHED SALVAGE CERTIFICATE OF TITLE, PERMIT TO DISMANTLE, TOTAL
LOSS CERTIFICATE, OR SIMILAR TYPE CERTIFICATE TO ISSUE: (PAINTING, REPLACED GLASS, ETC.)
Left Rear Fender or left side panel
Right Rear Fender or right side panel
Grill except on one ton or smaller trucks
List the original manufacturer's public VIN_______________________________________ Said Plate___ (DOES) or ___ (DOES NOT) remain
Pickup Box
properly attached in location and that said plate number ___ (HAS) or ___ (HAS NOT) been altered or mutilated in any way. Owner/rebuilder further
states that: (1) Owner/rebuilder rebuilt the vehicle or supervised its rebuilders, (2) Owner/rebuilder personally inspected the completed vehicle and it
Body or Bed
complies with all safety requirements set forth by the State of Mississippi and any regulations promulgated thereunder, (3) The identification numbers of
Deck Lid, tailgate or hatchback
the restored vehicle and its parts have not, to the knowledge of the owner, been removed, destroyed, falsified, altered or defaced, (4) The salvage
certificate document or out of state title certificate attached to the application has not to the knowledge of the owner/rebuilder been forged, falsified,
T-tops, moon roof, or whichever is present
altered or counterfeited, and (5) All information contained on the application and its attachments is true and correct to the knowledge of the owner. I
DISTRIBUTION: Original form & original bills
affirm under penalties of perjury, that all information contained in this affirmation and its attachments are true and correct to the best of my knowledge.
of sale with application for title. Make two (2)
copies for the Department of Public Safety
Inspector and retain a copy for owner records.
COMPLETE AND SUBMIT THIS APPLICATION
WITH THE VEHICLE COMPLETELY RESTORED
TYPE OR PRINT NAME
SIGNATURE OF APPLICANT
DATE
AND READY FOR INSPECTION.
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