homemade/assembled vehicle use · pdf filex x homemade/assembled vehicle. use declaration. use...

X X Homemade/Assembled Vehicle Use Declaration Use this form to certify and register a 2-, 3-, or 4-wheel homemade or assembled vehicle for highway/public roadway use. Take this completed form to your local vehicle licensing office along with the following documents: • Certificates of ownership (title) or notarized bills of sale for the vehicles used in the assembly • Bills of sale or invoices for all major component parts • Receipts for all parts used in the construction • Certificate of vehicle inspection completed by the Washington State Patrol • Certified scale weight slip • Declaration of Value form, TD-420-737 • Odometer disclosure statement if the model year is less than 10 years old • Frame certification (if applicable) • Bumper certfication (if applicable) Manufacturer/Builder certification This section must be filled out completely and signed. PRINT or TYPE Name Address City State ZIP code (Area code) Telephone number Email address (optional) Check to confirm required components have been installed Headlight Tail light Brake light Turn signals License plate lamp Speedometer Odometer Reflectors Horn Mirrors (L/R) Brakes Suspension system Muffler Tires Fenders/Splashguards Windshield (if applicable) Seatbelt system (if applicable) Bumpers (if applicable) Doors (if applicable) Hood (if applicable) As the manufacturer of this homemade/assembled vehicle, I certify under penalty of perjury under the laws of the state of Washington that it meets motor vehicle safety standards described in 49 Code of Federal Regulations (CFR) Part 571 and Washington State RCW 46.37 and WAC 204. If signing for a business, I have full authority to do so. Date and place (city or county) signed Signature Registered owner Registered owner name Registered owner name Answer the following 1. Are the supporting documents you provided complete, true, and accurate to the best of your knowledge? ....................................................................... Yes No 2. Is the vehicle properly equipped with all items required by RCW 46.12.750? ..................... Yes No 3. Does the vehicle comply with state and federal requirements? ................................ Yes No 4. To the extent permitted by law, do you expressly agree to indemnify, defend, and hold harmless the state of Washington, the Washington State Patrol, and the Department of Licensing from all claims, damages, losses, expenses, and costs arising out of the registration and operation of this vehicle? ..................................................................... Yes No I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Date and place (city or county) signed Signature RCW 46.01.310; 46.12.750; 46.80.010 WAC 204-10-022; 308-56A-455 TD-420-809 (R/7/16)WA

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Homemade/Assembled VehicleUse Declaration

Use this form to certify and register a 2-, 3-, or 4-wheel homemade or assembled vehicle for highway/public roadway use. Take this completed form to your local vehicle licensing office along with the following documents:

• Certificatesofownership(title)ornotarizedbillsofsaleforthevehiclesusedintheassembly• Billsofsaleorinvoicesforallmajorcomponentparts• Receiptsforallpartsusedintheconstruction• CertificateofvehicleinspectioncompletedbytheWashingtonStatePatrol• Certifiedscaleweightslip• DeclarationofValueform, TD-420-737• Odometerdisclosurestatementifthemodelyearislessthan10yearsold• Framecertification(ifapplicable)• Bumpercertfication(ifapplicable)

Manufacturer/Builder certificationThis section must be filled out completely and signed.

PRINT or TYPE Name

Address

City State ZIPcode

(Areacode)Telephonenumber Emailaddress(optional)

Checktoconfirmrequiredcomponentshavebeeninstalled

Headlight Tail light Brakelight Turn signals License plate lamp

Speedometer Odometer Reflectors Horn Mirrors(L/R)

Brakes Suspensionsystem Muffler Tires Fenders/Splashguards

Windshield(ifapplicable) Seatbeltsystem(ifapplicable) Bumpers(ifapplicable) Doors(ifapplicable) Hood (ifapplicable)

As the manufacturer of this homemade/assembled vehicle, I certify under penalty of perjury under the laws of the state of Washington that it meets motor vehicle safety standards described in 49 Code of Federal Regulations (CFR) Part 571 and Washington State RCW 46.37 and WAC 204. If signing for a business, I have full authority to do so.

Dateandplace(cityorcounty)signed Signature

Registered ownerRegisteredownername Registeredownername

Answer the following

1. Arethesupportingdocumentsyouprovidedcomplete,true,andaccuratetothebestofyour knowledge? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

2. IsthevehicleproperlyequippedwithallitemsrequiredbyRCW46.12.750? . . . . . . . . . . . . . . . . . . . . . Yes No

3. Doesthevehiclecomplywithstateandfederalrequirements? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

4. To the extent permitted by law, do you expressly agree to indemnify, defend, and hold harmless thestateofWashington,theWashingtonStatePatrol,andtheDepartmentofLicensingfrom all claims, damages, losses, expenses, and costs arising out of the registration and operation of this vehicle? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

Dateandplace(cityorcounty)signed Signature

RCW46.01.310;46.12.750;46.80.010WAC204-10-022;308-56A-455TD-420-809(R/7/16)WA

http://www.dol.wa.gov/forms/420737.pdf

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