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Fillable Printable Collectible Vehicle Certification For Emission Test Exemption

Fillable Printable Collectible Vehicle Certification For Emission Test Exemption

Collectible Vehicle Certification For Emission Test Exemption

Collectible Vehicle Certification For Emission Test Exemption

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Collectible Vehicle Certification
for Emission Test Exemption
Use this form to certify that your vehicle meets the definition of a collectible vehicle and is exempt from emission test
requirements. A collectible vehicle is defined as being unique or is of rare design, has limited production, and is an object
of curiosity.
Registered owner
PRINT or TYPE Name
Address
City State Zip Code
(Area code) Telephone number Email address
Vehicle identification number (VIN), if applicable Model year Make Model
Certification
If you answer “no” to any of the following questions, your vehicle does not qualify as collectible and must meet emission
test requirements.
1. Is this vehicle used primarily for car club activities, exhibitions, parades, functions of public interest,
a private collection, or used infrequently for other purposes?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
2. Do you have collectible vehicle or classic automobile insurance coverage that restricts the
vehicle mileage, use, or both? ........................................................ Yes No
3. Do you have another vehicle for personal use? ........................................... Yes No
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Date and place (city or county) signed Registered owner signature
The Department of Ecology may contact you for additional documented proof of collectible or classic vehicle
insurance, use of the collectible vehicle, or information regarding your other personal use vehicle.
If your vehicle no longer meets the definition of a collectible vehicle you must obtain an emission test and notify
the Department of Licensing.
RCW 46.04.123
TD-420-810 (R/9/17)WA
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When you have completed this form, please print it out and sign here.
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