DL-21SC (3-15)

W BsIlI:frlY,?-T,'fu,". sELF-CERTT FTCATTON OF VEHTCLE(S) OWNED/OPERATED
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION

A DRIVER INFORMATION
Driver License Number

Name

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AddfeSS:

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Po. Box number may be used in addition to the aclual residence address, bul cannot

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State

Citv

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Zio Code

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VEHICLE INFORMATION (list all vehicles owned or permitted to operate)
Plate #

Title #

VIN #

Year/Make

#

Title #

VIN #

Year/Make

Plate #

Tltle #

VIN #

YearlMake

Plate

l--l Viotation occured prior to 1ol1tos c STATEMENT OF OWNERSHIP/NON-OWNERSHIP lctrecr appropriate box and comptete statement)

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, hereby state that I own/or have permission to operate the vehicle(s) listed above.

PLEASE PRINT NAME

E,
E,

, hereby state that I do not own any vehicle(s).
PLEASE PRINT NAME

PLEASE PRINT NAME

hereby state that my income meets the guideline established for an economic hardship.

PLEASE PRINT NAME

hereby state that the vehicle(s) titled/registered in my name is/are inoperable.

E'

I certify that all information given on this statement is true and correct. I hereby authorize the Department to furnish the lgnition

Vendor with

icle-

record for the purpose of processing this form.

I- V- ro

DATE

SIGNATURE IN INK

WARNTNG: Misstatement of ,acts is a misdemeanor of the third degree punishable by fine of up to $2,500.00 and/or imprisonment up to one year (18 Pa. C.S. Section 4904(b))
D

STATEMENT OF VENDOR (complete statement after verifylng Section

B and C)
Phone Number

Vendor Name

city

Vendor Address

tr tr tr

I state I

Zip code

PRINT NAME

, hereby state that I verified with PennDOT