Out of State Vehicle Verification - Clean Air Car Check

1 Out of State Vehicle Verification Clean Air Car Check Emissions Testing Program Box, Crown Point, In 46308 Fax 219-661-8409 This document is to verify that the Vehicle identified below is physically stationed 300 miles or more from an Indiana Vehicle emis-sions testing station. A Copy of the current registration and the Out of State Application must be submitted with this form. This Verification will be used by the motorist as a supporting document to apply for an out of State extension from emissions testing which is required by Indiana law, 326 IAX 13-1 for Vehicle registration. This statement is to certify that on this _____ (day) of_____ (month), 20____ (Year), I have made a physical/visual inspection of the Vehicle identified below.

2 VIN:_____Model Year:_____ License Plate:_____Plate Expiration:_____ Registered Owner Name:_____ Current Vehicle Location:_____ Officer Name:_____Badge #:_____ Title:_____Agency:_____ Agency Address_____ City:_____State:_____Zip:_____ Telephone # (include extension if applicable):_____ Signature:_____Date:_____ All spaces on this form must be completed or the form will not be accepted. Additional information may be obtained at Allow ten business days for processing. For assistance call 219-661-8269. THIS FORM MUST BE COMPLETED BY A DULY CONSTITUTED FEDERAL, State , COUNTY OR CITY LAW ENFORCEMENT OFFICER.