Vehicle Services Bureau
Statement of Fact
Statement detailing additional information from expenditures
Under penalty of law (MCA 45-7-203), I certify that the statements made and information contained on this form are
true and correct to the best of my knowledge, information, and belief; I am the person named on this form; and, if
signing for a business entity or trust, I have full authority to do so.
Signature _____________________________________________________________________ Date ________________________
This is my legal signature
Printed name _______________________________________________________________________________________________
Montana county and state authorities reserve the right to reject any form that has been altered.
This form is available in alternate formats for people with disabilities.
P.O. Box 201431, 302 N Roberts, Helena, MT 59620-1431
Phone (406) 444-3661 Fax (406) 444-0116 email@example.com
Email Address ______________________________________________ Phone Number ___________________________________
Total Expenditures in Montana from specialty plate fees
Total collected from generic specialty plate fees
Expenditures in Montana from specialty plate fees