Free Temporary Exemption Application - Wisconsin

TEMPORARY EXEMPTION APPLICATION
Exemption From Vehicle Emission Inspection
MV2472 11/2004 s.110.20(9) Wis. Stats.

Clear form

Wisconsin Department of Transportation Research and Information P O Box 8070 Madison, WI 53708-8070

INSTRUCTIONS 1. Complete this application. Please be sure to indicate the date your vehicle will again be operated in Southeastern Wisconsin. 2. Mail this application, your renewal notice and registration fee to the address above. Upon receiving your application and fee, we will send you the new Certificate of Registration and renewal sticker. Shortly thereafter you will receive a Temporary Exemption Approval letter, which will contain instructions for completing the testing requirements. Take that letter with you when you have your vehicle tested. If you have questions, please call 608-266-1466.
DATE Vehicle is Expected to be Operated Again in Southeastern Wisconsin License Plate Number License Expires End of Month, Year

Vehicle Year

Vehicle Make

Vehicle Identification Number

Owner Name

Last

First

Middle Initial

Area Code - Telephone Number

Street Address

City

State

ZIP Code

Mailing Address if Different from Above

City

State

ZIP Code

I request temporary exemption from vehicle emission inspection because:
My vehicle is temporarily inoperable. Please explain why:

My vehicle is temporarily being operated in a location where emission inspections are not available. Please give location: Other, please explain:

I certify that to the best of my knowledge the information and statements on this application are true and correct. X

(Owner Signature)

(Date)

FOR OFFICE USE ONLY

Approved

Disapproved

Date Processed

Processor Name