MV-9 (3-17) |
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www.dmv.pa.gov |
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COMPLIANCE OR EXEMPTION |
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FOR THE PENNSYLVANIA CLEAN VEHICLES |
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For Department Use Only |
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PROGRAM (SELF-CERTIFICATION FORM) |
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Bureau of Motor Vehicles • P.O. Box 68593 • Harrisburg, PA 17106-8593 |
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INSTRUCTIONS: This self-certification form is to be used with an |
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Application for Certificate of Title for every model year 2008 or |
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newer passenger vehicle or light duty truck with a gross vehicle weight rating of 8,500 pounds or less in situations where: |
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1. The vehicle meets the certification requirements of the Pennsylvania Clean Vehicles Program; however, a Manufacturer’s |
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Certificate of Origin is not available. |
Complete Section C, in addition to Sections A, B, and E. NOTE: Individuals should list |
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their PA Driver’s License (PA DL) or Photo ID# in the space provided. Businesses should list their Business ID# (Bus. ID) where |
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indicated (i.e. E.I.N.). |
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2. The vehicle is exempt from the certification requirements of the Pennsylvania Clean Vehicles Program. Complete Section D, |
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in addition to Sections A, B and E. |
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A |
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VEHICLE INFORMATION |
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Vehicle Identification Number |
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Year |
___ ___ |
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Make |
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(Exclude tenths) |
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___ , ___ ___ ___ |
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B |
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Gross Vehicle Weight Rating |
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Current Odometer reading |
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VEHICLE OWNER INFORMATION |
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Last Name (or Full Business Name) |
First Name |
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Middle Name |
PA DL/Photo ID# or |
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Date of Birth |
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Bus. ID# |
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Co-owner Last Name |
First Name |
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Middle Name |
PA DL/Photo ID# |
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Date of Birth |
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C |
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Current Street Address |
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City |
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State |
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Zip Code |
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COMPLIANCE CERTIFICATION |
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r |
I certify that this vehicle is a model year 2008 or newer, with a gross vehicle weight rating of 8,500 pounds or less, with |
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less than 7,500 miles on the odometer and complies with U.S.E.P.A. and California emission control regulations. There is |
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D |
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evidence of this by a manufacturer’s installed label under the hood of the vehicle. |
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EXEMPTION CERTIFICATION |
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I certify that this vehicle is exempt from Pennsylvania Clean Vehicles Program certification compliance because: |
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r |
This is an emergency vehicle. |
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r |
This vehicle is being transferred for use exclusively off-highway. |
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r |
This vehicle was granted a national security or testing exemption under Section 203(b)(1) of the Clean Air Act (42 |
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U.S.C.A. Section 7522(b)(1)). |
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r This vehicle was acquired for the purpose of replacing a vehicle which was damaged, or became inoperative, beyond |
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reasonable repair or was stolen while out of the Commonwealth of Pennsylvania and the replacement vehicle was acquired |
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out of this Commonwealth at the time the previously owned vehicle was damaged, became inoperative or was stolen. The |
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Vehicle Identification Number of the vehicle that was replaced was _____________________________. |
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r This vehicle was transferred by inheritance or court decree. |
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r |
This vehicle was titled and registered while the owner or lessee was a resident of another state and the owner or lessee |
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is moving to Pennsylvania. |
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E |
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r This vehicle has more than 7,500 miles at time of completing the application for Pennsylvania Certificate of Title. |
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SIGNATURE |
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The signature below hereby certifies under penalty of law that the information contained herein is TRUE and CORRECT. |
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WARNING: Falsification to authorities is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or |
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imprisonment up to 1 year (18 Pa.C.S. Section 4904[b]). |
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_______________________________ |
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____________________________________________________________ |
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Applicant Signature |
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Date |
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____________________________________________________________ |
_______________________________ |
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Co-Owner Signature Visit us at www.dmv.pa.gov or call us at: |
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Date |
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1-717-412-5380 |
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In state: 1-800-932-4600 u TDD: |
1-800-228-0676 u Out-of-State: 1-717-412-5300 u TDD Out-of-State: |
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