STATE OF CALIFORNIA

DEPARTMENT OF MOTOR VEHICLES

A Public Service Agency ApplicAtion for temporAry SmoG exemption

for A Vehicle locAted out-of-StAte
(h&Sc 44011, cVc 20, 1653, 8800)

Your vehicle may qualify for temporary exemption from biennial smog requirements if it is temporarily located out of
state. You must provide the following information in order to determine eligibility for the exemption.

Section 1 Vehicle informAtion

VEhiclE idENtificatioN NumbER YEaR makE modEl VEhiclE licENsE NumbER

as of the vehicle has been located outside of california and is currently physically located/garaged at:
datE

stREEt addREss citY statE Zip codE

the vehicle is temporarily located out of state because

the vehicle cannot or is not required to be registered in the state of because

the above vehicle will continuously be located outside california until . the required smog certification
datE

will be obtained and submitted to dmV upon the vehicles return to california.
Contact information of person operating the vehicle out of state:
tRuE full NamE daYtimE tElEphoNE NumbER

( )
Section 2 certificAtion

the informAtion you Are proVidinG iS Subject to VerificAtion by dmV And your reGiStrAtion mAy be
Subject to cAncellAtion.
ExEcutEd oN (DAte) at (City) statE

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
pRiNt tRuE full NamE siGNatuRE daYtimE tElEphoNE NumbER

x ( )
mailiNG addREss citY statE Zip codE

note: Vehicles located in the following cities are ineligible for the exemption.

Nevada Mexico
carson city Reno tecate
centerville sparks tijuana
crystal bay stateline tijuana baja ca
Gardnerville stewart
Genoa Washoe city
Glenbrook Verdi
incline Village Zephyr cove
minden

REG 5103 (NEW 4/2014) WWW

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