Fillable Form Reg 256a - Miscellaneous Certifications printable pdf download

MISCELLANEOUS CERTIFICATIONS

STATE OF CALIFORNIA

Complete the appropriate section(s) and sign in Section F.

DEPARTMENT OF MOTOR VEHICLES

A Public Service Agency

LICENSE PLATE/CF NUMBER

VEHICLE/VESSEL ID NUMBER

YEAR/MAKE

DISABLED VETERAN CERTIFICATION

Check the appropriate box. Documentation is required. (SEE OTHER SIDE)

Disabled Veteran Only (CVC §9105)

Disabled veteran exempt registration is valid for one vehicle only. The vehicle may not be used for transportation for hire,

compensation, or profit. If a commercial vehicle, unladen weight must be less than 8,001 pounds.

As a disabled veteran (CVC §295.7) who, as a result of injury or disease suffered while on active service with the Armed

Forces of the United States, I am submitting a United States Department of Veterans Administration letter showing that:

I am rated as 100% disabled due to a diagnosed disease or disorder which substantially impairs or interferes with my

mobility.

I am so severely disabled as to be unable to move about without the aid of an assistant device.

I have lost or lost the use of, one or more limbs or have suffered permanent blindness as defined in Welfare and Institutions

Code §19153.

TAIpEI ECONOMIC AND CULTURAL OFFICE (TECO) R&TC § 10781

As required, attached to this application are photocopies of a Tax Exemption Card issued by the Board of Equalization

and an ID card issued by the Department of State.

INDIAN CERTIFICATIONS—Indians residing on a federally recognized indian reservation or rancheria.

CVC § 9104.5 and R&TC § 10781.1

Indian-owned vehicles driven on public highways are exempt from license fees only. Tribal owned vehicles used exclusively

within the boundaries of their tribe are exempt from weight and license fees.

I am a member of the _______________ tribe and living on the ___________________ federal reservation or rancheria.

This vehicle will be registered to the _________________________________________________________ tribe and

will

will not be used exclusively within tribal boundaries.

Residency must be verified by an authorized member of the tribal council or an official of the Bureau of Indian Affairs, U. S.

Government. Signature and residence verification is acceptable on tribal letterhead.

AUTHORIZED SIGNATURE

TITLE

DATE

STOLEN OR EMBEZZLED VEHICLE CERTIFICATION

I am the owner or title holder of the vehicle described above which was stolen/embezzled on or about ________________

DATE

This is what happened: ______________________________________________________________________________

________________________________________________________________________________________ I reported

the theft/embezzlement to _____________________________________. I was not in possession of this vehicle when the

renewal fees became due.

POLICE AGENCY

The police agency recovered the vehicle on ______________ and I took possession of the vehicle on _______________ .

DATE

CERTIFICATION OF VEHICLE FOR HUMAN HABITATION

Definition: Human habitation is living space which includes, but is not limited to: closets, cabinets, kitchen units or fixtures,

and bath or toilet rooms.

This is a new vehicle manufactured for human habitation.

This is a new vehicle that was modified for human habitation by a licensed van converter.

This vehicle was permanently modified (

camper attached

converted to motorhome.) The modification was

completed on _____________________ .

DATE

1. Cost of the complete vehicle before it was modified: .............................................................. $ __________________

2. Cost of changes, including labor: ............................................................................................ $ __________________

3. Total value: .............................................................................................................................. $ __________________

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.

SIGNATURE

DATE

DAYTIME PHONE NUMBER

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REG 256A (REV. 3/2012) WWW

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