COMPLIANCE OR EXEMPTION FOR THE PENNSYLVANIA …

1 The signature below hereby certifies under penalty of law that the information contained herein is TRUE and :Falsification to authorities is a misdemeanor of the third degree punishable by a fine up to $2,500 and/orimprisonment up to 1 year (18 Section 4904[b])._____Applicant Signature I certify that this vehicle is exempt from PENNSYLVANIA Clean Vehicles Program certification COMPLIANCE because:rThis is an emergency vehicle is being transferred for use exclusively vehicle was granted a national security or testing EXEMPTION under Section 203(b)(1) of the Clean Air Act (42 Section 7522(b)(1)).rThis vehicle was acquired for the purpose of replacing a vehicle which was damaged, or became inoperative, beyond reasonable repair or was stolen while out of the Commonwealth of PENNSYLVANIA and the replacement vehicle was acquiredout of this Commonwealth at the time the previously owned vehicle was damaged, became inoperative or was stolen.

2 TheVehicle Identification Number of the vehicle that was replaced was vehicle was transferred by inheritance or court vehicle was titled and registered while the owner or lessee was a resident of another state and the owner or lesseeis moving to vehicle has more than 7,500 miles at time of completing the application for PENNSYLVANIA Certificate of EXEMPTION CERTIFICATIONB VEHICLE OWNER INFORMATIONLast Name (or Full Business Name)Current Street AddressStateZip CodeA VEHICLE INFORMATIONM iddle NameFirst NameCo-owner Last NameMiddle NameFirst NameCityVehicle Identification NumberYearMakeGross Vehicle Weight RatingE SIGNATUREDateINSTRUCTIONS: This self-certification form is to be used with an Application for Certificate of Title for every model year 2008 ornewer passenger vehicle or light duty truck with a gross vehicle weight rating of 8,500 pounds or less in situations where:1. The vehicle meets the certification requirements of the PENNSYLVANIA Clean Vehicles Program; however, a Manufacturer s Certificate of Origin is notavailable.

3 Complete Section C, in addition to Sections A, B, and E. NOTE:Individuals should listtheir PA Driver s License (PA DL) or Photo ID# in the space provided. Businesses should list their Business ID# (Bus. ID) whereindicated ( ).2. The vehicle is exempt from the certification requirements of the PENNSYLVANIA Clean Vehicles Program. Complete Section D,in addition to Sections A, B and E. Current Odometer reading(Exclude tenths)___ ___ ___ , ___ ___ ___C COMPLIANCE CERTIFICATIONrI certify that this vehicle is a model year 2008 or newer, with a gross vehicle weight rating of 8,500 pounds or less, withless than 7,500 miles on the odometer and complies with and California emission control regulations. There isevidence of this by a manufacturer s installed label under the hood of the vehicle. Co-Owner Signature DatePA DL/Photo ID# orBus. ID#PA DL/Photo ID# Date of BirthDate of BirthCOMPLIANCE OR EXEMPTION FOR THE PENNSYLVANIA CLEAN VEHICLESPROGRAM (SELF-CERTIFICATION FORM)For Department Use OnlyBureau of Motor Vehicles Box 68593 Harrisburg, PA 17106-8593MV-9 (3-17) us at or call us at:In state: 1-800-932-4600 uTDD: 1-800-228-0676 uOut-of-State: 1-717-412-5300 uTDD Out-of-State: 1-717-412-5380