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CERTIFICATION OF OREGON RESIDENCY OR DOMICILE

CERTIFICATION OFOREGON RESIDENCY OR DOMICILE735-7182 (9-18) SECTION 1 CUSTOMER INFORMATIONNAMERESIDENCE ADDRESSMAILING ADDRESS (IF DIFFERENT)CITYZIP CODE(Instructions on back)IF BUSINESS, REPRESENTATIVE S NAMEDRIVER LICENSE/PERMIT NUMBERSTATE OF ISSUANCECITYSTATE (OR COUNTRY)ZIP CODEI certify that I qualify for an OREGON driver license, identification card, driver permit, or vehicleregistration because I am a resident of, or domiciled in, OREGON or the vehicle is eligible or required tohave OREGON further certify that the information provided on this form and the proof I have submitted is true andcorrect. I further certify that if I have submitted a copy of my previous year s OREGON Income TaxReturn as proof of DOMICILE or RESIDENCY , the OREGON Income Tax Return is a true photocopy of theoriginal and the original has been filed with the State of OREGON , Department of understand that under OREGON law, it is a crime to knowingly make any false statement relating toapplication for a driver license, identification card, driver permit, or registration of vehicles.

and residency provisions are covered in ORS 803.200, 803.350, 803.360, 807.062 and OAR -CERTIFICATION OF OREGON RESIDENCY OR DOMICILE (Instructions on back) 735-016-0010 through OAR 735-016-0070. SECTION 1 – CUSTOMER INFORMATION NAME

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