Form C52 C – Fill Out and Use This PDF

Emissions Exemption Form (Code 52)

ADEQ Air Quality Vehicle Emissions

Code 52 Exemption is issued for vehicles registered outside of the emissions control area, but within zip codes which include emissions testing or on Gila River Tribal lands. By signing this form, the applicant affirms that the vehicle(s) listed are not operated within the emissions control area for employment or school. Please provide the following information (print or type), sign, and return to any Motor Vehicle Division office, or mail to ADEQ at the address below.

Name:____________________________________________________________________________________________

Physical Address:___________________________________________________________________________________

County:_______________________________ City and Zip Code:_______________________________________

Legal Description of Residence: Section, Township, and Range can be found on the property tax evaluation notice and is required for identifying exemption eligibility, except for vehicles domiciled on Gila River Tribal lands.

Section:__________________ Township:______________________ Range:____________________

Residence Telephone:_______________________________________________________________________________________

Employer:________________________________________________________________________________________________

Employment Address:_______________________________________________________________________________________

List vehicle(s) used to commute to place of employment or school:

List vehicle(s) exempt from emissions testing:

The following information must be provided to verify eligibility and process your application, except for vehicles domiciled on Gila River Tribal lands.

1.A photocopy of the current registration for each vehicle listed.

2.A photocopy of a current utility bill in the name of the applicant, identifying the physical address of residence.

3.A photocopy of property owner’s tax evaluation notice, listing the residence township, range and section. If you do not own the property, a photocopy of the lease/rental agreement will be required.

For vehicles domiciled on Gila River Tribal lands, a letter from the Tribal Authority stating the registered owner of the vehicle is residing on Gila River Tribal lands.

Please sign below:

I hereby certify that the information supplied on this application is true, and that the exempt vehicle(s) listed are not used to commute into the vehicle emissions control area for work or school. (A.R.S. § 49-550, falsification of this application is a Class 2 Misdemeanor.)

Applicant’s Signature________________________________________________		Date:____________________________
ORIGINAL (WHITE) – MVD	COPY (YELLOW) – ADEQ (Not required when original mailed to ADEQ)
VEHICLE EMISSIONS – PHOENIX	VEHICLE EMISSIONS - TUCSON
600 N 40TH STREET, PHOENIX, AZ 85008	4040 N. 29TH STREET, TUCSON, AZ 85711