
Page 2 of 3DR 2395 (04/18/25)
Vehicle Identification Number (V I N) (REQUIRED)
Motor vehicle insurance or operator’s coverage is compulsory in the State of Colorado. Proof of
insurance is required prior to issuance of a registration. Non-compliance with this requirement
is a misdemeanor traffic offense. Pursuant to 42-4-1409, C.R.S., the penalties for failure to
have motor vehicle insurance coverage is a Class 1 Misdemeanor Traffic Offense punishable
by a mandatory minimum ten days imprisonment, or three hundred dollar fine, or both or a
mandatory maximum one year imprisonment, or one thousand dollar fine, or both shall be
imposed by section 42-4-1701(3)(a)(II) (A), C.R.S.; and
a. A minimum mandatory fine of not less than five hundred dollars or greater if imposed by
the court; and
b. At the discretion of the court, not less than forty hours of community service, subject to
the provisions of section 18-1.3-507, C.R.S.
c. A second or subsequent conviction within a period of five years following a prior
conviction, a minimum mandatory fine of not less than one thousand dollars.
Unless a person waives his or her confidentiality, the information contained in the person’s
motor vehicle record shall not be used for any purpose other than a purpose authorized by law,
pursuant to C.R.S. 42-2-121 (4)(a).
I certify, under penalty of perjury in the second degree, that the above facts are true and
accurate to the best of my knowledge.
Owner, Agent, Trustee, Dealer/Lienholder Agent Signature: Date (MM/DD/YY)
Printed Name of Owner, Agent, Trustee, Dealer/Lienholder Agent as it Appears on Identification:
Secure and Veriable ID Type REQUIRED:
Colorado D L Colorado I D
Other
ID Number Expires Date of Birth
Witness Signature Required. The undersigned witness affirms that the named owner of the vehicle
identified in this document presented the identification described above.
Witness Printed Name
Witness Signature Date (MM/DD/YY)