Fillable Printable Certification of Residency or Domicile - Oregon
Fillable Printable Certification of Residency or Domicile - Oregon
Certification of Residency or Domicile - Oregon
CERTIFICATION OF
OREGON RESIDENCY OR DOMICILE
735-7182 (11-11)
SECTION 1 – CUSTOMER INFORMATION
NAME
RESIDENCE ADDRESS
MAILING ADDRESS (IF DIFFERENT)
CITY
ZIP CODE
ThiscertificationisforuseinsupportofaclaimtoeitherbearesidentofOregonordomiciledinthis
state.Apersonmustbearesidentof,ordomiciledin,Oregon,andabusinessmustbearesidentof
Oregon, to beeligible to registera vehicle inthis state, unlessotherwise authorized orrequired by law.
Apersonmustbearesidentof,ordomiciledin,OregontobeeligibletoobtainanOregondriver
license,identificationcard,ordriverpermit,unlessotherwisespecificallyprovidedbylaw.Domicile
andresidencyprovisionsarecoveredinORS803.200,803.350,803.360,807.062andOAR
735-016-0010 through OAR 735-016-0070.
(Instructions on back)
IF BUSINESS, REPRESENTATIVE’S NAME
DRIVER LICENSE/PERMIT NUMBER
STATE OF ISSUANCE
CITY
STATE (OR COUNTRY)
ZIP CODE
IcertifythatIqualifyforanOregondriverlicense,identificationcard,driverpermit,orvehicle
registrationbecauseIamaresidentof,ordomiciledin,Oregonorthevehicleiseligibleorrequiredto
have Oregon registration.
IfurthercertifythattheinformationprovidedonthisformandtheproofIhavesubmittedistrueand
correct.IfurthercertifythatifIhavesubmittedacopyofmypreviousyear’sOregonIncomeTax
Returnasproofofdomicileorresidency,theOregonIncomeTaxReturnisatruephotocopyofthe
original and the original has been filed with the State of Oregon, Department of Revenue.
IunderstandthatunderOregonlaw,itisacrimetoknowinglymakeanyfalsestatementrelatingto
applicationforadriverlicense,identificationcard,driverpermit,orregistrationofvehicles.(ORS
803.385/ORS807.520)BothoffensesareClassAmisdemeanorsandarepunishablebyajail
sentence of up to one year, a fine of up to $6,250 or both.
SECTION 4 – ACCEPTABLE PROOF OF RESIDENCY OR DOMICILE VIEWED:
(FOR OFFICE USE ONLY)
SIGNATUREDATE
X
INITIALS
Oregon Income Tax Return (filed for the previous year)
Other:
SECTION 2 – VEHICLE INFORMATION
SECTION 3 – CERTIFICATION
PLATE NUMBERYEAR
VEHICLE IDENTIFICATION NUMBER (VIN)
MAKE
DATE / COUNTER NUMBER
STATE (OR COUNTRY)
STK# 300151
Use this form to support your claim to being domiciled in, or a resident of, Oregon, or your claim that the vehicle is eligible
or required to have Oregon registration. This form and the proof you submit do not guarantee the issuance of an Oregon
driver license, identification card, driver permit or vehicle registration.
1) The form must be complete, legible and signed.
2) Attach copies of the document(s) that are proof of your claim to either being domiciled in, or a resident of Oregon, or
proof that the vehicle is eligible or required to have Oregon registration. If your transaction is for a driving privilege or
identification card, the proof submitted proving you are domiciled in or a resident of Oregon is in addition to the
required proof of your current residence address as established in OAR 735-062-0030. For a complete list of
acceptable proofs of residence address go to www.oregondmv.com.
If you reside in Oregon, and need to provide proof that you are a resident of or domiciled in Oregon, a true copy
of your Oregon permanent or part-year income tax return filed with the Oregon Department of Revenue for the
previous tax year is acceptable proof with this form. If you filed as a part-year resident the income tax return
must show that you resided in Oregon at the end of that tax year. If you do not have a copy of your income tax
return, you may provide two or more of the following documents with this form:
• A property tax record, utility bills, rent receipts, a lease or rental agreement or other document that shows you reside in
Oregon;
• Enrollment records or other documentation that you are attending an educational institution maintained by public funds
and pay resident tuition fees;
• Motel, hotel, campground or recreational vehicle park receipts showing that you currently reside in Oregon and have
remained in Oregon for six consecutive months or more;
• A statement dated within the last 60 days from a relief agency or shelter that you have no actual residence, but currently
receive assistance in Oregon;
• Fuel receipts, motel receipts, or other documents showing you have lived in Oregon for at least six of the last twelve
months.
• Documents showing you have a current account at a bank or credit union in Oregon and the account has been open for
60 days or more;
• A document showing receipt of public assistance from an agency of the State of Oregon dated within the last twelve
months; or
• An Oregon voter registration card.
If you are domiciled in Oregon, but are temporarily out of state, you may provide one or more of the following
documents with this form:
1. A true copy of your Oregon permanent or part-year income tax return filed with the Oregon Department of Revenue
for the previous tax year. If you filed as a part-year resident, the income tax return must show that you resided in Oregon
at the end of that tax year.
2. Proof that you have continuously maintained an Oregon residence while absent from the state;
3. Proof that you own a residence in Oregon;
4. Proof that you are temporarily residing outside of Oregon for a period of limited duration (paying non-resident tuition at
an out of state school; temporary transfer of employment; temporary care of a family member out of state) and you have
maintained ties to Oregon such as a bank account or voter registration;
5. Proof that you are a member of the United States Armed Forces, or the spouse or domestic partner, or dependent child
residing with a member, and Oregon is listed as your home in military records. A copy of your military LES (Leave and
Earnings Statement) is acceptable proof.
For a business entity, one or more forms of documented proof are required and must be submitted with this
form. Acceptable proof includes, but is not limited to, the following:
1. Property tax records, utility bills, rent receipts, lease agreements or similar documents which show your business is
currently the occupant of an office or warehouse facility in Oregon, along with a copy of service records, fuel receipts,
garage receipts or other documents showing that vehicles are being operated in Oregon;
2. A permit number or other information that shows you or the business hold a permit or other authority issued under ORS
Chapter 825 for intrastate transportation;
3. Storage receipts, repair bills, or similar documents which show the vehicle has been left in Oregon; or
4. Dispatch, delivery, maintenance tax records, or other documentation that shows the vehicle(s) are being housed or
dispatched from a location within Oregon or are otherwise being operated in Oregon.
Instructions
