Exemption/extension Application Instructions (Page 2 of 2) in pdf

Exemption/Extension Application

The top portion of the form must be filled out by the owner or operator of the vehicle. The Vehicle Verification section of

the form must be filled out by an official from the state or city where the vehicle is located, unless the verification

section is not required according to the instructions. Any person who knowingly provides false information or

statements on this form according to Ohio Revised Code (ORC) 3704.05(H) is subject to civil and/or criminal penalties as

provided in Ohio Revised Code (ORC) 3704.06(C) and Ohio Revised Code (ORC) 3704.99(B).

Vehicle Information

Make:

Model:

Year:

License Plate:

Vehicle Identification Number (VIN):

Registration Expiration:

Owner Name:

Operator Name:



OH Address (No P O Boxes): (

Mail to this address)

Out of State Address: (

Mail to this address)

City:

County:

City:

County:

State, Zip:

Email address:

Daytime Telephone Number: (

)

*Phone number must be included. If an email address is provided, we will email you the certificate number for your vehicle registration

renewal. Sometimes this email goes to your spam or junk mail box.

Vehicle has been at the out of state address listed above since __________________________ for (check one)

(Enter Date)



Military

Student

Employment

Out of State Residence

Other (specify reason)____________________.

The vehicle will be returned by __________________. (Must be a date. Will not accept: unknown, not known, etc.)

(Enter Date or Estimated Date)

I certify that the above information is accurate to the best of my knowledge and is made under penalty of perjury.

Signature of Owner/Operator: _____________________________________________ Date: _____________________

Vehicle Location Verification

(see instructions)

Place a check () next to one of the following :



Local/State/Military/School Law Enforcement Officer

Government Agency

Local Motor Vehicle Agency

I certify that the vehicle described above is physically located within the geographical or law enforcement

jurisdiction of this agency, institution, or base.

Signed: _______________________________________Badge Number: ________________ Date: ______________

Print Name: _________________________________________________ Phone Number: ______________________

Police Department/School/Military Base/Agency:_________________________________________________________

Address, City, State, Zip: _______________________________________________________________________

EPA 3451 Rev June 2015

Exemption/extension Application Instructions Page 2

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