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Get PA 221 2007-2024

MV-221 9-07 PA Department of Transportation P. O. Box 68674 Harrisburg PA 17106-8674 STATEMENT OF NON-OPERATION OF VEHICLE S FOR DEPARTMENT USE ONLY PLEASE TYPE OR PRINT IN INK ALL INFORMATION NOTE 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 Print Name operation of the following motor vehicle s between // to // due Insurance Cancellation Date Insurance Replacement Date to lapse in insurance coverage. Last Name or Full Business Name First Name Middle Name PA DL/Photo ID or Bus. ID Date of Birth Telephone Number Co-Owner Last Name Middle Name PA DL/Photo ID Title Number License Plate Number Vehicle Identification Number Make Signature of Owner or Authorized Signer Date Signature of Co-Owner/Title of Authorized Signer 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. This form may be reproduced* Visit us at www. I hereby state that I did not operate or permit Print Name operation of the following motor vehicle s between // to // due Insurance Cancellation Date Insurance Replacement Date to lapse in insurance coverage. Last Name or Full Business Name First Name Middle Name PA DL/Photo ID or Bus. ID Date of Birth Telephone Number Co-Owner Last Name Middle Name PA DL/Photo ID Title Number License Plate Number Vehicle Identification Number Make Signature of Owner or Authorized Signer Date Signature of Co-Owner/Title of Authorized Signer WARNING Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to 2 500. Last Name or Full Business Name First Name Middle Name PA DL/Photo ID or Bus. ID Date of Birth Telephone Number Co-Owner Last Name Middle Name PA DL/Photo ID Title Number License Plate Number Vehicle Identification Number Make Signature of Owner or Authorized Signer Date Signature of Co-Owner/Title of Authorized Signer 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. This form may be reproduced* Visit us at www. I hereby state that I did not operate or permit Print Name operation of the following motor vehicle s between // to // due Insurance Cancellation Date Insurance Replacement Date to lapse in insurance coverage. Last Name or Full Business Name First Name Middle Name PA DL/Photo ID or Bus. ID Date of Birth Telephone Number Co-Owner Last Name Middle Name PA DL/Photo ID Title Number License Plate Number Vehicle Identification Number Make Signature of Owner or Authorized Signer Date Signature of Co-Owner/Title of Authorized Signer 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. This form may be reproduced* Visit us at www. .

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