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STATE OF TENNESSEE
DEPARTMENT
OF REVENUE
V
EHICLE SERVICES DIVISION
44
VANTAGE WAY
S
UITE 160
NASHVILLE, TENNESSEE 37243-8050
CERTIFICATE OF DESTRUCTION
FOR VEHICLE SERVICES
LICENSE PLATES, DECALS, TOPS, TITLES AND PLACARDS
I _________________________________certify that _________________________County
Clerk’s office has destroyed or transferred to a third party vendor the following: license plates,
decals, titles, TOPS and/or placards for destruction. (See Attached Listing).
I further certify that our office will maintain the original records relating to this destruction and
provide a copy of this certification to the Tennessee Department of Revenue’s Internal Audit and
Consulting Services Section and a copy to the Vehicle Services Division.
The records will be available for review in our office upon visitation by Auditors, Department of
Revenue Internal Auditors and/or designated Revenue personnel.
Clerk’s Office Signature ________________________________________Date______________
Third Party Vendor Signature____________________________________Date______________
Method of Destruction___________________________________________________________
Signature witnessed by me this________day of____________________________, 20____
Signed: ___________________________________________________________________
(Notary Public)
RV-F1323101
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