Fill and Sign the Template for Infection Control Policy Form

STATE OF ALASKA DIVISION OF MOTOR VEHICLES RECONSTRUCTED VEHICLE AFFIDAVIT This form must be completed by the legal owner of the vehicle at the time the vehicle is reconstructed. This is the person who contracted the work to be done. It is not to be completed by the person who performed the work, except in the case where the legal owner made the repairs to the vehicle. The owner must obtain a title in their name before the vehicle can be resold. Please Print. Y Year Make Body Style Color Weight N Previous Title Reconstructed By (Print Your Full Legal Name) Driver License Number Address State State City/State/Zip Frame: Where Purchased Serial Number (VIN) Date Where Purchased Serial Number (VIN) Date Where Purchased Serial Number (VIN) Date Body: Engine: PROOF OF PURCHASE AND OWNERSHIP (BILLS OF SALE, PREVIOUS TITLE, ETC.) MUST BE SUBMITTED WITH THIS AFFIDAVIT. BILLS OF SALE FOR ADDITIONAL PARTS OR MATERIALS ARE ALSO TO BE SUBMITTED. VEHICLE INSPECTION AGREEMENT TO HOLD HARMLESS: I, the undersigned applicant, understand that the undersigned officer is providing the identification inspection of my vehicle as a public service to me and the State of Alaska, Division of Motor Vehicles. I hereby authorize the inspecting officer to perform such tasks as necessary to complete said inspection and agree to hold harmless the inspecting officer, his/her agency, and the State of Alaska for any claims for damage arising from said inspection. Signature Date I CERTIFY THAT I HAVE INSPECTED THE VEHICLE AND THE SERIAL NUMBER (VIN) IS: Serial Number / VIN: This VIN agrees with title/supporting documents: YES The status of this vehicle has been checked on: NO NCIC/NICB ALVIN Signature of Inspecting Officer Agency Date Inspected Title/Badge Number City Where Inspected State I, do hereby swear under penalty of (Print Your Full Legal Name) law, the information contained in this affidavit is true, correct, and complete to the best of my knowledge and belief, and that all transactions were conducted in compliance with State laws. Subscribed and sworn to before me this day of , 20 Signature (Sign in front of DMV Representative or Notary) Date Notary or DMV Representative (AMVC & Office Location) My Commission Expires: Please complete the Operational Affidavit on the reverse. Additional Information: Form 829 (Rev. 07/2014) www.Alaska.gov/dmv A reconstructed vehicle is one that has been materially altered from the original construction. This alteration may consist of the removal, addition, or substitution of essential parts. Essential parts are considered to be the chassis/frame, body and engine. Title Requirements: • • • • • Complete Form 829, in full. Must have the vehicle inspected by Alaska State Troopers, local law enforcement in the State of Alaska or a DMV Representative. The original title from all vehicles used to reconstruct the vehicle, unless the titles were returned to DMV as “JUNKED”. All bills of sale and invoices for major parts used in the reconstruction. A lien release is required if a lien is recorded on DMV records. An Application for Title and Registration (Form 812). Operational Affidavit I certify that the vehicle complies with Alaska regulation 2 AAC 92.080(d)…“reconstructed vehicle means a vehicle that has been completely restored to operational, street legal condition.” I also certify the vehicle has been inspected to verify it is operational and is in satisfactory working condition for all the equipment listed below. (Signature at the bottom affirms all required equipment is installed and operational.) Requirement Regulation or Statute Vehicle Operational Safety/Seat Belts Headlights Tail Lights Reflectors Brake Lights License Plate Light Turn Signals 02 AAC 92.080(d) 13 AAC 04.270 13 AAC 04.020 13 AAC 04.025 13 AAC 04.030 13 AAC 04.035 13 AAC 04.025(c) 13 AAC 04.037(b) Hazard Lights Foot Brake Emergency Parking Brake License Plates 13 AAC 04.095(e-f) 13 AAC 04.205 13 AAC 04.205(b) AS 28.10.161 Requirement Windshield Wipers and Defroster Safety Glass Horn Mirror Steering Assembly Body Condition Energy Absorption Systems (Air Bags, Bumpers, etc.) Muffler(s) Tires Anti-spray Devices Regulation or Statute 13 AAC 4.225(a) 13 AAC 04.225(c-d) 13 AAC 04.225(f) 13 AAC 04.210(a) 13 AAC 04.220(a) 13 AAC 04.227(a) 13 AAC 04.227(b) 13 AAC 04.272 13 AAC 04.215 13 AAC 04.230 13 AAC 04.265 I have personally reviewed the information on this application and certify under penalty of perjury that to the best of my knowledge and belief the information on this application is true and correct. (NOTE: Making a false statement or omitting a material fact is subject to a maximum penalty of $10,000 or 1 year imprisonment or both per AS 11.56.210 and AS 28.35.135.) Print Owner Name Owner Signature Date Note: The equipment above is what is required for passenger cars, pickups, vans, etc. Other types of vehicles may have different requirements. Form 829 (Rev. 07/2014) www.Alaska.gov/dmv