Utah State Tax Commission
Exemption Affidavit For Utah Emission Testing
Affidavit For Vehicles Purchased From Dealers In Non-Emission Counties
Division of Motor Vehicles · PO Box 30412, Salt Lake City, UT 84130 · Telephone 801-297-7780 or 1-800-368-8824
Get forms online - tax.utah.gov
WARNING: Providing false or misleading information on this form is a crime, subject to penalty under Utah Criminal Code 76-8-504.
Dealers: Complete this form and provide a copy to the nearest motor vehicle office with the registration application and a copy to the purchaser.
If you have questions about this form, call 1-800-DMV-UTAH.
Purchaser: Provide a copy of this form with the emission Certificate of Compliance to your county Department of Health.
Salt Lake Valley
Utah County Health Department
Davis County Environmental Health
Bureau of Air Quality Program
P.O. Box 618
788 E. Woodoak Lane
477 23rd Street
3255 North Main Street
Farmington, Utah 84025
Murray, Utah 84107-6379
Ogden, Utah 84401
Spanish Fork, Utah 84660
Utah plate number
I understand that Utah Code requires that I have my vehicle tested for emissions prior to registration in the State of Utah.
Because the above described vehicle was purchased in a non-emission county from a licensed Utah motor vehicle
dealer, I am unable to meet this requirement.
I expect to return to
Salt Lake County
on Month _________________ Day _____ Year ______.
I agree to have the vehicle tested for emissions and will submit an emissions Certificate of Compliance to the Department of
Health in the county that I live within 10 days from my return.
Finally, I affirm that I have entered into a written agreement with the dealer named below regarding costs that I may incur to
obtain an emission Certificate of Compliance.
Failure to submit a Certificate of Compliance may result in revocation of the registration.
Purchaser's signature (no power-of-attorney acceptable)
Purchaser's street address
I am a licensed Utah motor vehicle dealer whose legal place of business is in __________________ County, a non-emission county.
I have entered into written agreement with the above named purchaser regarding cost that may be incurred by the
purchaser to obtain an emission Certificate of Compliance for the county where the purchaser lives.
Dealer or authorized representative's signature
Bonded dealer number