Fillable Form Reg 256a - Miscellaneous Certifications (Page 2 of 2) in pdf

Form Reg 256a - Miscellaneous Certifications Page 2

Download a blank fillable Form Reg 256a - Miscellaneous Certifications in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Reg 256a - Miscellaneous Certifications with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

DOCUMENTATION FOR SECTION A ONLY

VA Regional Office Name _____________________________________________

Address _____________________________________________________________

City _______________________________State _______Zip Code ____________

Subject: Medical Statement for Service-Connected Disabled Veterans in order to obtain waiver of California

Department of Motor Vehicles registration fees.

This is to certify that _________________________________________ meets the service-connected qualifications

(Veteran’s Name)

of a Disabled Veteran, according to the provisions of the California Vehicle Code Section 295.7, as identified below

(check one or more boxes):

Has a service-connected disability which has been rated at 100% disabled due to a diagnosed disease or disorder

which substantially impairs or interferes with mobility; or,

Is so severely disabled as to be unable to move without the aid of an assistive device; or,

Has lost, or has lost use of, one or more limbs; or,

Has suffered permanent blindness as defined in Section 19153 of the California Welfare and Institutions code.

I certify that I, _______________________________________________ am an authorized employee of the United

(print name)

States Department of Veterans Affairs and I certify under penalty of perjury under the laws of the State of California

that the information I have provided is true and correct and that I will retain information sufficient to substantiate

the certification and shall make that information available for inspection by the Medical Board of California, at the

department’s request. (CVC Section 22511.55). (Note: Assembly Bill 2777, Statutes of 2010, removed the requirement

that a physician sign this certification.)

Executed at (City/State):_________________________________________________ Date:____________________

Signature___________________________________ Printed Name _______________________________________

Phone #:___________________________________

Veteran

: Deliver this form to:

1) A local DMV Field Office, or

By mail to:

Special Processing Unit, MS D238

DMV

P.O. Box 932345

Sacramento, CA 94232-0001

REG 256A (REV. 3/2012) WWW

Clear Form

Form Reg 256a - Miscellaneous Certifications Page 2

Related Articles

Related forms

Related Categories