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[Pages:1]A Public Service Agency VEHICLE IDENTIFICATION NUMBER

NONRESIDENT MILITARY EXEMPTION STATEMENT

(50 US CODE SECTION 574)

MAKE OF VEHICLE

VEHICLE LICENSE NUMBER

You qualify for this exemption if your duty station is located in California and your vehicle is not used in a trade or business.

I am on active duty in the U.S. Uniformed Services with the ________________ . I am now stationed at ________________________ ,

BRANCH OF SERVICE

DUTY STATION

California, with the ____________________________________ . This can be verified by my commanding officer, who can be reached at

UNIT

_____________________ . I am not a resident of California, my legal residence is _______________________________________ .

TELEPHONE NUNBER

STATE

Military Identification Verified _______________________________________________________________ .

OFFICE

DATE

ID #

DMV TECH INITIALS

THE INFORMATION YOU ARE PROVIDING IS SUBJECT TO DEPARTMENT OF DEFENSE VERIFICATION AND DMV AUDIT.

EXECUTED ON (DATE)

AT (CITY)

STATE

I certify under penalty of perjury that the foregoing is true and correct.

PRINT TRUE FULL NAME

SIGNATURE

MAILING ADDRESS

CITY

DAYTIME TELEPHONE NUMBER

(

)

STATE

ZIP CODE

REG 5045 (NEW 5/2004) WWW

A Public Service Agency VEHICLE IDENTIFICATION NUMBER

CUT ON LINE AND SAVE FOR YOUR RECORDS

NONRESIDENT MILITARY EXEMPTION STATEMENT

(50 US CODE SECTION 574)

MAKE OF VEHICLE

VEHICLE LICENSE NUMBER

You qualify for this exemption if your duty station is located in California and your vehicle is not used in a trade or business.

I am on active duty in the U.S. Uniformed Services with the ________________ . I am now stationed at ________________________ ,

BRANCH OF SERVICE

DUTY STATION

California, with the ____________________________________ . This can be verified by my commanding officer, who can be reached at

UNIT

_____________________ . I am not a resident of California, my legal residence is _______________________________________ .

TELEPHONE NUNBER

STATE

Military Identification Verified _______________________________________________________________ .

OFFICE

DATE

ID #

DMV TECH INITIALS

THE INFORMATION YOU ARE PROVIDING IS SUBJECT TO DEPARTMENT OF DEFENSE VERIFICATION AND DMV AUDIT.

EXECUTED ON (DATE)

AT (CITY)

STATE

I certify under penalty of perjury that the foregoing is true and correct.

PRINT TRUE FULL NAME

SIGNATURE

MAILING ADDRESS

CITY

DAYTIME TELEPHONE NUMBER

(

)

STATE

ZIP CODE

REG 5045 (NEW 5/2004) WWW

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