Form Mv-100 - Affidavit Of An Assembled Vehicle Inspection printable pdf download

FORM MV-100 (06-08)

DEPARTMENT OF REVENUE

MOTOR VEHICLE DIVISION

Affidavit of an Assembled Vehicle Inspection

1. I, _____________________________________________________________

(Printed Owner’s Full Legal Name)

________________________________________________________________________

(Address)

______________________________________________ GA. _____________________

(City)

(Zip code)

____________________________________

_____________________________

(Drivers License Number)

(Date of Birth)

am requesting the Department of Revenue (DOR) to inspect

________________________ ____________________________ _________________

(Vehicle Identification Number)

(Make and model)

(Year of Construction)

that has been manufactured using new or used vehicle parts from a manufacturer’s kit or

manufacturer’s fabricated parts and,

2. Owner understands and asserts that such vehicle may not have been manufactured

according to applicable federal motor vehicle safety standards issued pursuant to 49

U.S.C.A. Section 30101. et. seq. and,

3. Owner understands and agrees that any inspection performed by DOR does not

certify, unless specifically stated herein, that such vehicle meets any applicable state or

federal motor vehicle safety standards and,

4. Owner indemnifies and holds harmless the State of Georgia and any of its agencies

from any defects in the assembly or construction of such vehicles

5. Owner authorizes DOR to conduct an inspection of such vehicle to determine whether

safety equipment defined in Chapter 8 of Title 40 of the Official Code of Georgia,

Annotated (O.C.G.A.) has been installed and is operational.

6. Owner agrees to maintain:

a. Vehicle in compliance with Chapter 8 of Title 40, O.C.G.A.

b. Maintain motor vehicle liability insurance coverage

c. Any applicable federal emission standards issued pursuant to 42 U.S.C.A.

Section 7401 through Section 7642, the ‘Clean Air Act’ as amended

7. Owner agrees such vehicle shall be subject to any subsequent safety inspection by any

peace officer of any state or commonwealth.

___________________________________________

________________________

Owner’s Signature

Date

___________________________________________

________________________

Notary Public

Date

_________________________________________________________________

Notary Public Commission Expiration Date – County of Appointment

Any alterations, corrections or strikeouts will automatically void this form

Form Mv-100 - Affidavit Of An Assembled Vehicle Inspection

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