
The signature below hereby certifies under penalty of law that the information contained herein is TRUE and CORRECT.
WARNING: Falsification to authorities is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or
imprisonment up to 1 year (18 Pa.C.S. Section 4904[b]).
____________________________________________________________ _______________________________
____________________________________________________________ _______________________________
Applicant Signature
I certify that this vehicle is exempt from Pennsylvania Clean Vehicles Program certification compliance because:
r This is an emergency vehicle.
r This vehicle is being transferred for use exclusively off-highway.
r This vehicle was granted a national security or testing exemption under Section 203(b)(1) of the Clean Air Act (42
U.S.C.A. Section 7522(b)(1)).
r This vehicle was acquired for the purpose of replacing a vehicle which was damaged, or became inoperative, beyond
reasonable repair or was stolen while out of the Commonwealth of Pennsylvania and the replacement vehicle was acquired
out of this Commonwealth at the time the previously owned vehicle was damaged, became inoperative or was stolen. The
Vehicle Identification Number of the vehicle that was replaced was _____________________________.
r This vehicle was transferred by inheritance or court decree.
r This vehicle was titled and registered while the owner or lessee was a resident of another state and the owner or lessee
is moving to Pennsylvania.
r This vehicle has more than 7,500 miles at time of completing the application for Pennsylvania Certificate of Title.
D EXEMPTION CERTIFICATION
B VEHICLE OWNER INFORMATION
Last Name (or Full Business Name)
Current Street Address
State
Zip Code
A VEHICLE INFORMATION
Middle Name
First Name
Co-owner Last Name
Middle Name
First Name
City
Vehicle Identification Number
Year
Make
Gross Vehicle Weight Rating
E SIGNATURE
Date
INSTRUCTIONS: This self-certification form is to be used with an Application for Certificate of Title for every model year 2008 or
newer passenger vehicle or light duty truck with a gross vehicle weight rating of 8,500 pounds or less in situations where:
1. The vehicle meets the certification requirements of the Pennsylvania Clean Vehicles Program; however, a Manufacturer’s
Certificate of Origin is not
available. Complete Section C, in addition to Sections A, B, and E. NOTE: Individuals should list
their PA Driver’s License (PA DL) or Photo ID# in the space provided. Businesses should list their Business ID# (Bus. ID) where
indicated (i.e. E.I.N.).
2. The vehicle is exempt from the certification requirements of the Pennsylvania Clean Vehicles Program. Complete Section D,
in addition to Sections A, B and E.
Current Odometer reading
(Exclude tenths)
___ ___ ___ , ___ ___ ___
C COMPLIANCE CERTIFICATION
r I certify that this vehicle is a model year 2008 or newer, with a gross vehicle weight rating of 8,500 pounds or less, with
less than 7,500 miles on the odometer and complies with U.S.E.P.A. and California emission control regulations. There is
evidence of this by a manufacturer’s installed label under the hood of the vehicle.
Co-Owner Signature Date
PA DL/Photo ID# or
Bus. ID#
PA DL/Photo ID#
Date of Birth
Date of Birth
COMPLIANCE OR EXEMPTION
FOR THE PENNSYLVANIA CLEAN VEHICLES
PROGRAM (SELF-CERTIFICATION FORM)
For Department Use Only
Bureau of Motor Vehicles • P.O. Box 68593 • Harrisburg, PA 17106-8593
MV-9 (3-17)
www.dmv.pa.gov
Visit us at www.dmv.pa.gov or call us at:
In state: 1-800-932-4600 u TDD: 1-800-228-0676 u Out-of-State: 1-717-412-5300 u TDD Out-of-State: 1-717-412-5380