Looking for a Arkansas Department Of Finance And Administration Forms And Templates? Download it for free!

Alternative Fuels Vehicle Conversion Notification Form - Arkansas Department Of Finance And Administration

DF&A-Revenue Division

STATE OF ARKANSAS

Motor Fuel Tax Section

P. O. Box 1752

Department of Finance

Little Rock, AR 72203-1752

Phone: (501)682-4800

and Administration

Fax: (501)682-5599

ALTERNATIVE FUELS VEHICLE CONVERSION NOTIFICATION

FORM

PLEASE PRINT OR TYPE

Arkansas Code Ann. § 26-62-214 provides that any alternative fuels supplier, garage, mechanic, owner, or operator of a motor

vehicle who converts or causes a vehicle to be converted to enable the vehicle to be operated on any type of alternative fuels

shall report to the Department of Finance and Administration the required information listed below about the converted vehicle

within ten (10) days after the conversion.

Please complete this form in its entirety. If you have more than one converted vehicle, please submit a separate form for each

vehicle. If you have any questions, please contact the Motor Fuel Office at 501-682-4800.

Vehicle Owner’s Name__________________________________________________________________________

Address______________________________________________________________________________________

City________________________ State__________ Zip Code__________ Phone Number (

)______________

VEHICLE INFORMATION

Vehicle Make & Model_____________________________________________Year________________________

VIN_________________________________________ License Number_________________________________

VEHICLE CONVERSION INFORMATION

Date of Conversion _________________ Fuel Conversion to:

CNG_____ Other (list type)_______________________

Name of Conversion Dealer or Mechanic __________________________________________________________

Address_____________________________________________________________________________________

City________________________ State__________ Zip Code_______ Phone Number (

)________________

INSTALLER AGREES, UNDER PENALTY OF PERJURY, THAT THE INFORMATION GIVEN ON THIS FORM

IS, TO THE BEST OF THEIR KNOWLEDGE, TRUE, ACCURATE, AND COMPLETE.

__________________________________________________

______________________________________

Conversion Dealer or Mechanic’s Signature

Date

Alternative Fuels Vehicle Conversion Notification Form - Arkansas Department Of Finance And Administration