VSA 26 (10/01/2012)
STREET ADDRESS CITY
STATE ZIP CODE
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and
that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of
perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
CERTIFICATION
INSPECTOR LICENSE NUMBERINSPECTOR NAME (print)
INSPECTOR SIGNATURE
VERIFIED COMPLETED BY STATE INSPECTOR
the internal combustion engine has been removed
a traction battery pack has been installed that is distinct from the
vehicle's original auxiliary battery system
the fuel tank has been removed and not replaced
an electric motor has been installed to drive the wheels of the
vehicle
STATION NAME TELEPHONE NUMBER
INSPECTION INFORMATION
INSPECTION DATE (mm/dd/yyyy) STATION NUMBER
BODY TYPE VEHICLE IDENTIFICATION NUMBER (VIN)
VEHICLE
COLOR
SECONDARYPRIMARY
MODEL
VEHICLE INFORMATION
MAKEYEAR
OWNER'S RESIDENCE/HOME/BUSINESS ADDRESS (Apt # if applicable)
CITY
ZIP CODESTATE
OWNER INFORMATION
OWNER'S FULL LEGAL NAME (last, first, mi, suffix) OR BUSINESS NAME (if business owned) DMV CUSTOMER NUMBER / FEIN / SSNTELEPHONE NUMBER
PURPOSE: Use this form to certify that a vehicle has been converted to electric propulsion.
INSTRUCTIONS: The vehicle owner completes the "Owner Information" and "Vehicle Information" sections. The form is then presented to a
licensed state vehicle inspector who completes the "Inspection Information" section. The vehicle owner must then submit
this form and vehicle title with any applicable fees to the address above, attention Vehicle Branding Work Center. Contact
the Vehicle Branding Work Center with any questions regarding the completion of this form at 804-367-1179.
CONVERTED ELECTRIC VEHICLE
CERTIFICATION
DATE (mm/dd/yyyy)
