Out-of-State Verification Inspection Form

Out-of-State Verification
Inspection Form
Massachusetts Registry of Motor Vehicles
Vehicle Safety and Compliance Services
P.O. Box 55892
Boston, MA 02205-5892
Fax: 857-368-0816
This form is used to verify that your vehicle or equipment is out-of-state, and will miss its required annual Massachusetts vehicle
inspection. Please type or print all requested information. Forms not accompanied by satisfactory proof will be rejected.
Plate Type (from Registration) _________________________
Registration (Plate) Number ________________________
Vehicle Identification Number (VIN)___________________________________________________________________________
Note: Please also print your Out-of-State Address, Plate, and VIN information on the bottom of this form.
Registration Expiration Date___________________________
Current Odometer Reading__________________________
Owner’s Name _____________________________________
Vehicle/Equipment Year ___________________________
Mailing Address ____________________________________
Vehicle/Equipment Make ___________________________
City, State, Zip _____________________________________
Vehicle/Equipment Model __________________________
Out-of-State Mailing Address__________________________
Expected Return to Massachusetts Date ________________
City, State, Zip _____________________________________
Out of State Telephone Number ______________________
(if applicable)
Please check one (1)
I hereby certify that the above vehicle or equipment has passed the inspection required by the jurisdiction in which the vehicle is
currently domiciled. As proof, I have attached a copy of my passing inspection receipt. (Note: For commercial vehicles, check this
box and attach a copy of an FMVSA / “DOT” Inspection Form or FMVSA / “DOT” equivalent state inspection.)
I hereby certify that the jurisdiction in which the above vehicle or equipment is currently domiciled lacks an inspection program or
does not inspect vehicles registered in other jurisdictions.
I hereby certify that I am temporarily residing in another jurisdiction because I am . . .
A student
In military service
A seasonal resident
Other
Within three (3) days of being returned to the Commonwealth of Massachusetts (15 days if inspected by another state/jurisdiction), the vehicle or
equipment identified on this form must have a vehicle inspection performed by a Massachusetts vehicle inspection station, as required by law. I
swear, under the penalties of perjury, that to the best of my knowledge the statements I have made herein are accurate, and I agree to abide by the
laws and regulations set forth by the Commonwealth of Massachusetts. Please note: This authorization expires on the last day of the month twelve
(12) months from the date received.
Vehicle Owner/Representative’s Signature
Date
*** Please clearly print the address where this form can be mailed back to you in the receipt section at the bottom of this form and
keep the receipt with the vehicle once approved by the RMV. ***
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Out-of-State Verification Approval & Receipt
EXPIRES LAST DAY OF MONTH ONE YEAR FROM DATE STAMPED BELOW.
(Keep this receipt with your registration until inspected in Massachusetts.)
Plate Type____________________________
Registration (Plate) Number _________________________________
Vehicle Identification Number VIN ______________________________________________________________
(RMV Use Only)
↓↓ Please clearly print name and out-of-state address in this box ↓↓
_____________________________________________
_____________________________________________
_____________________________________________
T21307-0712