Form Reg 256 - Statement Of Facts Page 2
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1
2STATEMENT OF FACTS
Complete the appropriate section(s) in full (including vehicle description) and sign Section H.
LICENSE PLATE/CF NUMBER
VEHICLE/VESSEL ID NUMBER
YEAR/MAKE
E.
STATEMENT FOR VEHICLE BODY CHANGE (OWNERSHIP CERTIFICATE REQUIRED)
The current market value of the vehicle or vessel is: $________________ .
Changes were made at a cost of $________________ on this date ________________ .
This is what I changed: Check all that apply:
Unladen Weight changed because __________________ (Public Weighmaster Certifi cate is required. Exception: Trailers)
Motive Power changed from ________________ to ________________ .
Body Type changed from ________________ to ________________ .
Number of Axles changed from ________________ to________________ .
F.
STATEMENT FOR NAME CHANGE OR CORRECTION (OWNERSHIP CERTIFICATE REQUIRED)
Please print
I, _______________________________ and _______________________________ are one and the same person.
My name is misspelled. Please correct it to: _________________________________________________________
I am changing my name from ________________________________ to __________________________________
G.
STATEMENT OF FACTS
I, the undersigned, state:
H.
APPLICANT’S SIGNATURE
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
PRINTED LAST NAME
FIRST NAME
MIDDLE NAME
DAYTIME PHONE NUMBER
(
)
SIGNATURE
DATE
X
REG 256 (REV. 1/2007) WWW
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