Secretary Of State-Affirmation For Low-Speed Vehicle Form
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Secretary of State
This space for use by
Secretary of State
ffirmation for Low-Speed Vehicle
Secretary of State
Vehicle Services Department
Titles Division
501 S. Second St., Rm. 609
Springfield, IL 62756-5100
217-557-0717
Owner(s) Name: _____________________________________________________________________________________
Address: ____________________________________________________________________________________________
City/State/ZIP Code: __________________________________________________________________________________
Vehicle Identification Number: __________________________________________________
Year: ___________________ Make: ___________________ Model: ___________________
Fuel Type:
Gasoline
Electric
Other: _________________________________________________________________
I/we hereby affirm that the vehicle described for registration meets Federal Motor Vehicle Safety Standard No. 500 (49 CFR
571.500 and is a four-wheeled vehicle with a maximum speed greater than 20 mph, but not greater than 25 mph.
Furthermore, I/we hereby acknowledge it is only lawful to operate said vehicle upon any street in Illinois where the posted
speed limit is 30 mph or less, except where prohibited by Illinois Department of Transportation, township, county, or other
unit of government as specified by 625 ILCS 5/11-1426.2.
The information provided is true and correct and will abide by the Mandatory Insurance Law requiring liability insurance
throughout the registration period.
________________________________________________________________________
________________________
Signature of Owner
Date
________________________________________________________________________
________________________
Signature of Co-Owner
Date
The following documentation must be submitted to the Secretary of State’s office along with this Affirmation for Low-Speed
Vehicle:
• Application for Vehicle Transaction (VSD 190)
• Appropriate tax forms and fees payable to Illinois Department of Revenue
• Applicable fee payable to Secretary of State
♲
Printed on recycled paper. Printed by authority of the State of Illinois. May 2013— 1 — VSD 796.2
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