Transcription of (Instructions on back) - oregon.gov
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(Instructions on back) - oregon.gov
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.
certification of oregon residency or domicile 735-7182 (11-11) section 1 – customer information name residence address mailing address (if different) city zip code
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