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Form T20132-0404 - Application For An Antique Motor Vehicle Plate Or Year Of Manufacture Registration Plate Form Page 2

Certification and Affidavit of Vehicle Owner

I hereby certify that the ________ ________________________________________________ (antique vehicle) owned

Year

Make & Model

by me and described in the accompanying RMV registration application is over 25 years old and will be maintained and

operated solely for use in exhibitions, club activities, parades and other functions of public interest (including test drives

to prepare for such functions and transportation to and from repair facilities) and will not be used primarily for the

transportation of passengers or goods over any way. I also certify that if I am registering the vehicle with a Year of

Manufacture plate, that I came into possession of the plate in a lawful manner.

This document must be signed in the presence of a Notary Public of the Commonwealth.

I swear that I am the owner of the vehicle described in the accompanying application form and that the above

Certification and Affidavit is true and correct. I understand that I am signing this document under the penalties of

perjury and may be punished for false swearing.

________________________________

__________________________________

______/______/______

Signature of Vehicle Owner

Printed Name of Vehicle Owner

Date

Notarization: On this _______ day of ______________________, ________, before me, the undersigned notary public,

personally appeared ________________________________________ (name of document signer), proved to me through

satisfactory evidence of identification, which were _____________________________________, to be the person whose

name is signed above, and who swore or affirmed to me that the contents of the document are truthful and accurate to the

best of his/her knowledge and belief.

________________________________

__________________________________

______/______/______

Signature of Notary Public

Printed Name of Notary Public

My Commission Expires

Place notary seal above

Registry Use Only:

Batch No. __________________________ Date:___________________________

Antique Plate No. Issued: _____________________________

Antique Vanity Plate No. Issued:________________________

Year of Manufacture Plate No. Issued:____________Year ______Approved By:___________________

Attention Branches: Submit Completed Forms to Special Plates Section.

T20132-0404

Form T20132-0404 - Application For An Antique Motor Vehicle Plate Or Year Of Manufacture Registration Plate Form Page 2