Secretary Of State-Affirmation For Electric Vehicle Form

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Secretary of State
This space for use by
Affirmation for Electric Vehicle
Secretary of State
Secretary of State
Applicable fees and forms may be submitted along with
Vehicle Services epartment
this request form to the address at left.
501 S. Second St.
License plate registration application forms may be
Springfield, IL 62756
obtained in person at most Secretary of State facilities, by
mail, or by calling 800-252-8980
Owner(s) Name: __________________________________________________________________________________
Address:
________________________________________________________________________________________
City/State/ZIP Code: ______________________________________________________________________________
Vehicle Identification Number: ______________________________________________________________________
Year:______________________ Make: ______________________ Model:__________________________________
Electric Vehicle Types:
Originally Manufactured Electric Vehicle
Converted Electric Vehicle*
*For Converted Vehicles, please submit photographs of the front, back and side of the vehicle, along with
photographs of the electric motor and battery.
I/we hereby affirm that the vehicle described for registration is a motor vehicle of the first division or a motor
vehicle of the second division weighing 8,000 pounds or less and propelled exclusively by an electric engine and
not utilizing motor fuel.
__________________________________________________________
______________________________
Owner’s Signature
Date
__________________________________________________________
______________________________
Owner’s Signature
Date
The following documentation must be submitted to the Secretary of State’s office along with this Affirmation for
Electric Vehicle:
• Application for Vehicle Transaction (VSD 190)
• Appropriate tax forms and fees payable to the Illinois Department of Revenue
• Applicable fee payable to Secretary of State
• If a converted vehicle, photographs of the front, back and side of the vehicle along with photographs of the
electric motor and battery
Printed by authority of the State of Illinois. July 2013 – 1 – VSD-861

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