Low-Power Scooter Agent Temporary Registration

1 DR 2579 (05/27/15) COLORADO DEPARTMENT OF REVENUE Division of Motor Vehicles Registration Section Agent Use OnlyLow-Power Scooter Registration Decal Number Low-Power Scooter Agent Temporary RegistrationExpire MonthExpire Year (three years from the purchase date) 42-3-102( ), 42-2-103, 42-3-105, 42-3-311 & Code Of Colorado, Regulation 1 CCR 204-10 Rule 40. Low Power ScooterThis Form is to be used for Low-Power Scooter Registration Agent Use Only Individual owners applying directly to the Department for Low-Power Scooter Registration should complete the DR 2701 Low-Power Scooter Registration Application that can be accessed at Scooter InformationVehicle Identification Number (VIN)YearMakeModelFuel Type CC s WattageCC s or WattageColorPurchase DateLow-Power Scooter Agent NameAgent/Dealer NameOwner/Applicant InformationOwner/Applicant Last NameOwner/Applicant First NameAdditional Owner/Applicant Last NameAdditional Owner/Applicant First NameAdditional Owner/Applicant Last NameAdditional Owner/Applicant First NameLegal Address (PO Boxes are not permitted)CityStateZIPM ailing Address (If different from Legal Address)CityStateZIPLast Name as it appears on IdentificationFirst Name as it appears on Identification Colorado DL Colorado ID Other.

2 ID#ExpiresDOBThe undersigned witness affirms that the named owner of the vehicle identified in this document presented the identification described SignatureWitness Printed NameDateLow-Power Scooter Registration Agent should complete this form in its entirety. Incomplete forms will be returned for correction. No refunds will be issued to the applicant by State Registrations. Applicant will be directed back to the LPS Registration Agent for refunds. 1. Validate the owners/customers Secure and Verifiable Validate the owner s proof of insurance for this Low-Power Scooter . Photocopy the proof of insurance for this Low-Power Scooter and mail in with this form. Do not send originals. Photocopy will not be Mail this form, photocopy of ownership document and photocopy of the proof of insurance to the address listed below:Colorado Department of Revenue Division of Motor Vehicles PO Box 173350 Denver, CO 80217-3350 Affidavit of Low-Power Scooter ComplianceThe following affidavit must be completed by the owner prior to submitting this form to register the Low-Power Scooter .

3 The Low-Power Scooter listed above meets the following criteria: A self-propelled vehicle designed primarily for use on roadways with not more than three wheels in contact with the ground. Has no manual clutch. Has either of the following (check one): A cylinder capacity not exceeding fifty cubic centimeters (50 cc s) if powered by internal combustion; or A wattage not exceeding four thousand four hundred seventy-six (4,476) if powered by electricity. I swear or affirm in accordance with section 24-12-102, , under penalty of perjury that I now have in effect a complying policy of motor vehicle insurance including an operator s policy pursuant to part 6 of article 4 of title 10, , or a certificate of self-insurance to cover the vehicle or operator of the vehicle for which this Registration is issued. I understand that such insurance must be renewed so that coverage is continuous. Noncompliance is a misdemeanor traffic offense, that the minimum penalty for such offense is a five-hundred-dollar fine, and that the maximum penalty for such offense is one year s imprisonment and a one-thousand-dollar fine.

4 Owner s shall be required as a condition of obtaining a Registration card to sign an affirmation clause that appears on the of Owner (required)DateInstructionsSecure and Verifiable Identification (DR 2841) is required to obtain a Registration in the State of Scooter Registration may be issued by: Division of Motor Vehicles, Registration Section, or, A registered Low-Power Scooter AgentApplicant1. Submit the following: The completed application on the reverse side of this form A photocopy of the notarized Bill of Sale, Invoice or other proof of ownership (photocopies will not be returned) Check or Money Order made payable to the Agent or Colorado Department of Revenue2. Y ou will receive a decal to be affixed to the frame that supports the seat of the Low-Power The operator of the Low-Power Scooter must have in their possession: A valid Driver s License or Minor Driver s License; A valid registrationIssuing Office1. V erify all information completed by the applicant and obtain secure and verifiable identification (see form DR 2841) on the DR 2579 form or DR 2842 Issue a numbered decal and indicate decal number assigned on the front of this The original application is to be submitted to the Division of Motor Vehicle Registration Section.

5 A copy of the completed application becomes the customer s Registration upon approval by the State of Colorado or authorized Low-Power Scooter Division of Motor Vehicles Registration Section submit fee to Cashier Section. Low-Power Scooter Agent submit fee and Low-Power Scooter Monthly Report to Division of Motor Vehicles, Registration A registered Low-Power Scooter Agent shall retain one dollar for each Low-Power Scooter Registration .