Free Exemption Affidavit for Utah Emission Testing - Utah

Affidavit For Vehicles Purchased From Dealers In Non-Emission Counties

Exemption Affidavit For Utah Emission Testing

Utah State Tax Commission

WARNING: Providing false or misleading information on this form is a crime, subject to penalty under Utah Criminal Code 76-8-504.
Dealers: Complete this form and return the WHITE and YELLOW copies to the nearest motor vehicle office with the registration application. Give the PINK copy to the purchaser. If you have questions about this form, call 1-800-DMV-UTAH. Purchaser: Send the PINK copy with the emission Certificate of Compliance to your county Department of Health.

Salt Lake Valley Health Department 788 E. Woodoak Lane Murray, Utah 84107-6379 (801) 313-6720
Vehicle Description
Year Make

Weber-Morgan Health Department 477 23rd Street Ogden, Utah 84401 (801) 399-7140

Utah County Health Department Bureau of Air Quality Program 3255 North Main Street Spanish Fork, Utah 84660 (801) 851-7600

Davis County Environmental Health County Courthouse P.O. Box 618 Farmington, Utah 84025 (801) 546-8860

Model

VIN

Utah license number

Purchaser Affidavit I, the undersigned, understand that Utah Code requires that I have my vehicle tested for emissions prior to registration in the State of Utah. Because the above described vehicle was purchased in a non-emission (attainment) county from a licensed Utah motor vehicle dealer, I am unable to meet this requirement. I expect to return to Davis County Salt Lake County Utah County Weber County

on Month _________________ Day _____ Year ______. Furthermore, I affirm and agree that I will have the vehicle tested for emissions and will submit an emissions Certificate of Compliance to the Department of Health in the county that I live within 10 days from my return. Finally, I affirm and agree that I have entered into a written agreement with the dealer named below regarding costs that I may incur to obtain an emission Certificate of Compliance.

Advisory: It is in YOUR best interest to have this vehicle's emission tested as soon as possible. By signing this exemption form, you will be responsible for any repairs necessary for this vehicle to qualify for an emission Certificate of Compliance.
Failure to submit a Certificate of Compliance may result in Revocation of your registration; and/or Nullification of any agreement with the dealer to cover repair costs associated with obtaining an emission Certificate of Compliance.
Purchaser's name Purchaser's signature (no power-of-attorney acceptable) X City County Telephone number State ZIP code

Purchaser's street address

Dealer Affidavit I, the undersigned affirm that I am a licensed Utah motor vehicle dealer whose legal place of business is in __________________ County, a non-emission county. I further affirm that I have entered into written agreement with the above named purchaser regarding cost that may be incurred by the purchaser to obtain an emission Certificate of Compliance for the county where the purchaser lives.
Dealer's name Dealer or authorized representative's signature X
WHITE - Utah State Tax Commission (dealer make a photocopy of original) CANARY - County Emissions Office PINK - Purchaser

Bonded dealer number

Utah State Tax Commission Approval

Utah registration of this vehicle is hereby authorized by completion of the above affidavits.
Approval signature (Utah State Tax Commission) X
TC-820 Rev. 9/06

EO number

Date approved