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2. First Name*
3. Last Name*
5. Daytime Phone Number*
6. Email*
8. VIN*
10. Model Year*
11. Model*
13. Make*
14. License Plate*
16. I am voluntarily cancelling the registration because the vehicle was*
    -- Select One --Inoperable or storedJunkedNot being operatedRegistered Out-of-StateRepossessed, stolen, or wreckedSalvaged by an insurance companySoldTraded
17. Date*
    Date
19. Vehicle cannot be operated on any highway or public road until owner has obtained mandatory liability insurance and the vehicle registration has been reinstated with county tag office.
21. Electronic Signature Agreement*

    Pursuant to Georgia Code Section 40-2-3, "Any person who shall make any false statement in any application for the registration of any vehicle, or in transferring any certificate of registration, or in applying for a new certificate of registration, shall be guilty of false swearing, whether or not an oath is actually administered to him if such statement shall purport to be under oath. On conviction of such offense, such person shall be punished as provided by Code Section 16-10-71".

    1. I, the submitter for this Tag Cancellation, warrant the truthfulness of the information provided in this application.
23. Electronic Signature*
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field