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Utah State Tax Commission

Exemption Affidavit of Utah Safety and Emission

TC-810

Rev. 10/00

Requirements for Vehicles Not In Utah

WARNING: Providing false or misleading information on this form is a crime, subject to penalty under

Utah Criminal Code 76-8-504.

Return completed and signed form with the renewal documents or with registration applications and necessary fees (do not send cash

in the mail). If you have questions about this form, telephone (801) 297-3508 or 1-800-368-8824 outside the Salt Lake City area.

I, the undersigned, understand that under Utah Code I am required to have my vehicle safety inspected and tested for emissions in Davis,

Salt Lake, Utah, or Weber Counties prior to registration in the State of Utah. I hereby certify that the following described vehicle is

temporarily out of state and is now located at:

___________________________________ ____________________________ _________________

_________

___________

Physical address (not P.O. Box)

City

County

State

ZIP code

as a result of _________________________________ and will return to Utah on month_______ day _______year ______ ,

and I am unable to meet the above requirements. I further certify and agree to the following:

You must check one box in each section that applies to your out-of-state location.

Section 1 - Safety Inspection

This vehicle is temporarily in a state shown in Section 1A on the reverse of this form. If so, you must obtain and enclose a

certificate of safety inspection, or equivalent, from the state where the vehicle is located. Keep a copy of the certificate in your

vehicle.

This vehicle is not located in a state shown in Section 1A on the reverse side of this form. I affirm and agree that the vehicle

will be kept in a safe mechanical condition and that upon returning to the State of Utah, I will have the vehicle safety inspected

and will submit proof of the safety inspection to the Utah Highway Patrol Safety Inspection Division, 4501 South 2700 West,

Salt Lake City, Utah 84119 within 10 days after the "return to Utah" date shown above.

Section 2 - Emissions Inspection

When in Utah, I am not a resident of Davis, Salt Lake, Utah, or Weber County. No emissions test is required.

When in Utah, I am a resident of Davis, Salt Lake, Utah, or Weber County and this vehicle is temporarily located in a city, county, or

state area shown in Section 2A on the reverse side of this form. If so, you must include a certificate of emissions, inspection, or

equivalent, from the city, county, or state where the vehicle is located. Keep a copy of the certificate in your vehicle.

When in Utah, I am a resident of Davis, Salt Lake, Utah, or Weber County and this vehicle is not located in a city, county, or state

area shown in Section 2A on the reverse side of this form. I affirm and agree that I will have the vehicle tested for emissions and will

submit proof of the emissions inspection to the Department of Health in the county in which I reside within 10 days after the

"return to Utah" date shown above.

This vehicle is fueled by diesel and

is not

part of a fleet licensed under the International Registration Plan. I affirm and agree

that I will have the vehicle tested for emissions and will submit proof of the emissions inspection to the Department of Health in the

county in which I reside within 10 days after the "return to Utah" date shown above.

Salt Lake City County

City County Health Department

Davis County Environmental Health

Weber County

Health Department

of Utah County

County Courthouse

Health Department

788 E. Woodoak Lane #150

3255 North Main Street

P.O. Box 618

2570 Grant Ave.

Murray, Utah 84107-6379

Spanish Fork, Utah 84660

Farmington, Utah 84025

Ogden, Utah 84401

(801) 313-6720

(801) 343-4600

(801) 546-8860

(801) 399-8108

Year

Make

Utah license number

New expire. date

Model

Fuel VIN

Owner's name

Telephone number

Owner's UTAH street address

City

County

State

ZIP code

Owner or authorized representative's signature

Date

WHITE - Individual YELLOW - U.H.P. PINK - County Health Department

Form Tc-810 - Exemption Affidavit Of Utah Safety And Emission Requirements For Vehicles Not In Utah - 2000

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