Application Clean Air Vehicle Decals Form – Fill Out and Use This PDF

Fee applies to all new and replacement decals. Fee does not apply to exempt agencies (except replacement decals) and owner transfer. Only the registered owner of record may apply. For vehicle qualification, check the California Air Resources Board (ARB) website at arb.ca.gov. To avoid your application from being delayed or returned unprocessed, check dmv.ca.gov/vr/decal.htm, for information on completing this form.

SECTION A — CURRENT REGISTERED OWNER INFORMATION (name printed must match DMV records)

a Change of address (DMV 14) form is also required if the address listed below is a recent change of address, or contains a separate mailing address, currently not on DMV records.

tRUE FUll NaME (LAST, FIRST, MIDDLE) oR BUSiNESS NaME		DRiVER liCENSE oR iD CaRD NUMBER
Co-oWNER tRUE FUll NaME (LAST, FIRST, MIDDLE)		DRiVER liCENSE oR iD CaRD NUMBER
PHYSiCal RESiDENCE oR BUSiNESS aDDRESS (INCLUDE ST.,AVE., RD., CT., ETC.)	UNit No. (INDICATE APT., STE., ETC.)
CitY	CoUNtY	StatE			ZiP CoDE
MailiNG aDDRESS (IF DIFFERENT FROM PHYSICAL ABOVE)	UNit No. (INDICATE APT., STE., ETC.)
CitY	CoUNtY	StatE			ZiP CoDE

SECTION B — CLEAN AIR VEHICLE DECALS (must check at least one box in all three sections)

the above described vehicle meets California exhaust standards AND Federal Inherently Low-Emission Vehicle (ILEV) standards for California Clean air Vehicle Decals which permit access to High occupancy Vehicle (HoV) lanes.

NOTE: if this vehicle is a replacement Enhanced at PZEV or tZEV for a previous Enhanced at PZEV or tZEV total loss salvage or non-repairable vehicle which had Clean air Vehicle Decals, also complete Section C.

SECTION C — ENHANCED AT PZEV OR TZEV CLEAN AIR VEHICLE REPLACEMENT DECALS (total loss/salvage or non-repairable only)

Effective January 1, 2012, DMV may issue new Clean air Vehicle Decals to owners of qualifying Enhanced at PZEVs or tZEVs purchased to replace Enhanced at PZEVs or tZEVs that were originally issued Clean air Vehicle Decals prior to the statutory 40,000 Enhanced at PZEV/tZEV decal limit, and that have been subsequently declared total loss/salvage or non-repairable. applications under this section must be filed within six months of the date of the original Enhanced at PZEV’s or tZEV’s total loss.

olD VEHiClE liCENSE PlatE NUMBER	olD VEHiClE iDENtiFiCatioN NUMBER	olD YEaR
olD MaKE	olD MoDEl	olD DECal NUMBER (iF BEiNG REPlaCED)

other:

REG 1000 (REV. 3/2014) WWW

SECTION D — REPLACEMENT DECALS OR ID CARD ONLY

Current Decal Number:

Replacement iD Card only

Replacement Decals (if any original decals are later located or received, the original decals are canceled and are no longer valid and must be returned to DMV.)

Replacement decals are needed because decals were:

Stolen (a copy of a police report is required.)

lost, Damaged, Destroyed, Faded (a completed/signed statement giving details in Section E is required.)

if the vehicle was involved in an accident complete the following:

Front Bumper Damaged/Replaced

Rear Bumper Damaged/Replaced

Both Front/Rear Bumper Damaged/Replaced

(a copy of a repair shop report showing repair to front [if green decals] and/or rear [both white or green decals] of vehicle must be submitted, if all three [white] or four [green] decals are not surrendered to DMV. if only one bumper was damaged/ replaced, you must surrender the remaining decal[s] from the other bumper.)

Not received from DMV (no fee). allow 30 days from issue date before applying.

Not received from prior owner of vehicle.

other:

Disposition of Decals (MUST enter number [even if zero] in BOTH A and B):

NOTE: Decals are issued in sets of three (white) or four (green) and a new decal number will be assigned. all damaged, faded, and remaining decals must be removed from vehicle and surrendered (including decals in pieces) to DMV with this application (tape to a separate sheet).

a - total number of decals lost, Damaged, Destroyed, Faded, Not Received, or Stolen:				.
B - total number of decals surrendered to DMV with this application:		. if less than three (white) or four (green), (1) explain

in Section E why the decals are unobtainable, and (2) state that there are no remaining decals on the vehicle.

SECTION E — STATEMENT OF FACTS (please explain clearly)

SECTION F — CERTIFICATION (original signature and date required)

the registered owner mailing address is valid, existing, and an accurate mailing address. i consent to receive service of process at this mailing address pursuant to Vehicle Code Section 1808.21, Code of Civil Procedure Sections 415.20, subdivision (b), 415.30, subdivision (a), and 416.90. the signature for a company or business must include the printed name of the company/business and an authorized representative’s countersignature on the signature line.

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

PRiNtED NaME	DaYtiME tElEPHoNE NUMBER
	(	)
SiGNatURE oF REGiStERED oWNER	DatE
X

REG 1000 (REV. 3/2014) WWW