REG 5103, Application for Temporary Smog Exemption for a ...

STATE OF CALIFORNIA

DEPARTMENT OF MOTOR VEHICLES

?

A Public Service Agency

ApplicAtion for temporAry SmoG exemption

for A Vehicle locAted out-of-StAte

(h&Sc ¡ì44011, cVc ¡ì¡ì20, 1653, 8800)

Your vehicle may qualify for temporary exemption from biennial smog requirements if it is temporarily located out of

state. You must provide the following information in order to determine eligibility for the exemption.

Section 1 ¡ª Vehicle informAtion

VEhiclE idENtificatioN NumbER

as of

datE

YEaR

makE

modEl

VEhiclE licENsE NumbER

the vehicle has been located outside of california and is currently physically located/garaged at:

stREEt addREss

citY

statE

Zip codE

the vehicle is temporarily located out of state because

the vehicle cannot or is not required to be registered in the state of

because

the above vehicle will continuously be located outside california until

datE

. the required smog certification

will be obtained and submitted to dmV upon the vehicle¡¯s return to california.

Contact information of person operating the vehicle out of state:

tRuE full NamE

daYtimE tElEphoNE NumbER

(

)

Section 2 ¡ª certificAtion

the informAtion you Are proVidinG iS Subject to VerificAtion by dmV And your reGiStrAtion mAy be

Subject to cAncellAtion.

ExEcutEd oN (DAte)

at (City)

statE

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and

correct.

pRiNt tRuE full NamE

siGNatuRE

daYtimE tElEphoNE NumbER

x

mailiNG addREss

(

citY

)

statE

Zip codE

note: Vehicles located in the following cities are ineligible for the exemption.

Nevada

carson city

centerville

crystal bay

Gardnerville

Genoa

Glenbrook

incline Village

minden

REG 5103 (NEW 5/2014) WWW

Reno

sparks

stateline

stewart

Washoe city

Verdi

Zephyr cove

Mexico

tecate

tijuana

tijuana baja ca

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