This form is used to verify that your vehicle is at least 300
miles from an Indiana vehicle emissions testing station, and
will miss its required Indiana vehicle emissions test. Get PDF version.
| *VIN: |
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*Confirm VIN: |
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*Year: |
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| *Make: |
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*Model: |
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| *Plate
Expiration Date:
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(mm/dd/yyyy)
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| *Registered
Owner's Name:
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| *Registered
Street Address:
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| *City: |
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*State:
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*ZIP:
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| *Out of State
Address (Current Vehicle Location):
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| *City: |
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*State:
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*ZIP:
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| *Expected
Date Vehicle will be Returned to Indiana:
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| *Contact Phone
Number:
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| *Contact Email
Address:
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| Contact Name (If Other than the Registered
Owner):
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I hereby certify that the above
listed vehicle is currently out of state because I
am:
(check all that apply)
A Student
On Work Assignment
In Military Service
A Seasonal Resident
Other (Explain):
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I submit the following documentation
as proof** of my current status: (select
one)
Current College Tuition Bill
Documentation on Employer Letterhead
Military Orders
Utility Bill from Out of State Residence
(Must be no more than 60 days prior to today's
date)
Emissions Test from state where vehicle is
located
Out of Area Vehicle
Verification |
Please upload the document specified
above (JPG or PDF files only)
If you are
unable to upload documentation, you may exit this online
application and submit your paper application by mail.
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**Proof should indicate dates of semester,
work, military service, etc.
If unable to provide any of the above documentation
as proof that the vehicle is currently located out of
state, you must also complete and submit an "Out of Area Vehicle
Verification” form along with your application
for approval.
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PROCESSING FEES:
Standard Processing - $40
Please allow ten business days for processing
Rush Processing - $50
For applications received before 12 p.m. CST,
Monday through Saturday, processing will occur the same
business day.
Applications received after 12 p.m. CST, Monday through
Saturday, or any time on Sunday, processing will occur
the next business day.
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| By clicking
SUBMIT, I swear, under the penalties of perjury,
that to the best of my knowledge the statements
I have made herein are accurate, and I agree to
bring the vehicle identified on this form in for
an emissions test at an Indiana Clean Air Car
Check vehicle emissions testing station within
fifteen (15) days of being returned to the State
of Indiana. |
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| Additional information may be required. |
