Form 256A – Fill Out and Use This PDF

A. DISABLED VETERAN CERTIFICATION

Check the appropriate box. Documentation is required. (SEE OTHER SIDE)

Disabled Veteran Only (CVC §9105)

Disabled veteran exempt registration is valid for one vehicle only. The vehicle may not be used for transportation for hire, compensation, or proit. If a commercial vehicle, unladen weight must be less than 8,001 pounds.

As a disabled veteran (CVC §295.7) who, as a result of injury or disease suffered while on active service with the Armed Forces of the United States, I am submitting a United States Department of Veterans Administration letter showing that:

I am rated as 100% disabled due to a diagnosed disease or disorder which substantially impairs or interferes with my mobility.

I am so severely disabled as to be unable to move about without the aid of an assistant device.

I have lost or lost the use of, one or more limbs or have suffered permanent blindness as deined in Welfare and Institutions Code §19153.

B. TAIpEI ECONOMIC AND CULTURAL OFFICE (TECO) R&TC §10781

As required, attached to this application are photocopies of a Tax Exemption Card issued by the Board of Equalization and an ID card issued by the Department of State.

C. INDIAN CERTIFICATIONS—Indians residing on a federally recognized indian reservation or rancheria. CVC §9104.5 and R&TC §10781.1

Indian-owned vehicles driven on public highways are exempt from license fees only.Tribal owned vehicles used exclusively within the boundaries of their tribe are exempt from weight and license fees.

I am a member of the _______________ tribe and living on the ___________________ federal reservation or rancheria.

This vehicle will be registered to the _________________________________________________________ tribe and

will	will not be used exclusively within tribal boundaries.

Residency must be veriied by an authorized member of the tribal council or an official of the Bureau of Indian Affairs, U. S. Government. Signature and residence veriication is acceptable on tribal letterhead.

AUTHORIZED SIGNATURE

TITLE

DATE

X

D. STOLEN OR EMBEZZLED VEHICLE CERTIFICATION

I am the owner or title holder of the vehicle described above which was stolen/embezzled on or about ________________

DATE

This is what happened: ______________________________________________________________________________

________________________________________________________________________________________ I reported

the theft/embezzlement to _____________________________________. I was not in possession of this vehicle when the

The police agency recovered the vehicle on ______________ and I took possession of the vehicle on _______________ .

DATE	DATE
E. CERTIFICATION OF VEHICLE FOR HUMAN HABITATION

Deinition: Human habitation is living space which includes, but is not limited to: closets, cabinets, kitchen units or ixtures, and bath or toilet rooms.

This is a new vehicle manufactured for human habitation.
This is a new vehicle that was modiied for human habitation by a licensed van converter.
This vehicle was permanently modiied (	camper attached	converted to motorhome.) The modiication was
completed on _____________________ .
DATE
1. Cost of the complete vehicle before it was modiied:		$ __________________
2. Cost of changes, including labor:		+
		$ __________________
3. Total value:		=	0
		$ __________________

F. AppLICANT’S SIGNATURE

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

DOCUMENTATION FOR SECTION A ONLY

VA Regional Ofice Name _____________________________________________

Address _____________________________________________________________

City _______________________________State _______Zip Code ____________

Subject: Medical Statement for Service-Connected Disabled Veterans in order to obtain waiver of California Department of Motor Vehicles registration fees.

This is to certify that _________________________________________ meets the service-connected qualiications

(Veteran’s Name)

of a Disabled Veteran, according to the provisions of the California Vehicle Code Section 295.7, as identiied below

(check one or more boxes):

Has a service-connected disability which has been rated at 100% disabled due to a diagnosed disease or disorder which substantially impairs or interferes with mobility; or,

Is so severely disabled as to be unable to move without the aid of an assistive device; or,

Has lost, or has lost use of, one or more limbs; or,

Has suffered permanent blindness as deined in Section 19153 of the California Welfare and Institutions code.

I certify that I, _______________________________________________ am an authorized employee of the United

(print name)

States Department of Veterans Affairs and I certify under penalty of perjury under the laws of the State of California that the information I have provided is true and correct and that I will retain information suficient to substantiate the certiication and shall make that information available for inspection by the Medical Board of California, at the department’s request. (CVC Section 22511.55). (Note: Assembly Bill 2777, Statutes of 2010, removed the requirement that a physician sign this certiication.)

Executed at (City/State):_________________________________________________ Date:____________________

Signature___________________________________ Printed Name _______________________________________

Phone #:___________________________________

Veteran: Deliver this form to:

1)A local DMV Field Ofice, or

2)By mail to: DMV: Special Processing Unit, MS D238

P.O. Box 932345 Sacramento, CA 94232-0001

REG 256A (REV. 3/2012) WWW