For more information, please call: 410-768-7000 (to speak with a customer service representative).
TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov
Vehicle Emissions Inspection Program – Certied Statement
For more information, please call: 1-800-638-8347 (touch tone calls only), 1-800-950-1MVA (1682) (to speak with a customer service representative),
From Out-of-State: 1-301-729-4550, TTY for the hearing impai red: 1-800-492-4575. Visit our website at: www.marylandmva.com
Vehicle Emissions Inspection Program - Certified Statement
de l i aM e t aDDI RSC : y l nO esU AVM
Tag Number Title Number Vehicle Identication Number Year Make
tsr iF - ren wO elc iheV fo emaN t saLe l dd iM
e d oC p i Ze t a tSy t n u oCy t iCsserd d A teer tS
e d oC p i Ze t a tSy t n u oCy t iC
s s e r d d A y r a r o pme T
Section 2: Owner’s Statement of Facts - The vehicle listed in Section 1 is not in compliance with the requirements of the Vehicle
Emissions Inspection Program due to the reason stated below. Attach additional information if necessary.
I certify, under penalty of law, that the statements made above are true and correct to the best of my knowledge and belief,
under Section 12-109(b) of the Maryland Vehicle Law.
e t aDr e bmu N e n o h p e l e T
Section 3: Repair Facility Statement of Facts
The vehicle listed in Section 1 has been under repair/storage at our facility from to
Repair Facility Name Phone Number
I certify under penalty of law, that the statements made above are true and correct to the best of my knowledge and belief, under
Section 12-109(b) of the Maryland Vehicle Law.
Repair Facility Manager Date
Section 4: Out-of-State Verification - If vehicle listed in Section 1 is temporarily located out-of-state, a law enforcement ocial,
from the state where the vehicle is located, must verify the vehicle is located in that state and complete this section.
✔ one of the following: ❒ Local/State/Federal Law Enforcement Officer ❒ School Security Officer ❒ Military Law Enforcement Officer
I certify that the vehicle described in Section 1 is located in this state and was observed in:
noe t a tSytnuoC/yt iC
# D I / egdaB
erutang iS s ’ la i c i f fO
# enohpe l e T
es aB y r a t i l iM/ l oohcS / ycnegA
Section 1: Vehicle Information
6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062