APPENDIX U

CERTIFICATION OF THE PRESENT STATUS OF VEHICLESALTERED, MODIFIED OR RE-MANUFACTURED AFTER FIRST SALE FORM

Vehicle Identification Number
Body Identification Number
(If different than chassis)
Current Classification of Vehicle Stated on Federal Motor Vehicle Safety Standards Tag
(Must be same as found in 49 CFR 571.3)
Original Vehicle Model Name and/or Number
Chassis / Body
Original Manufacturer Name
Alterer/Modifier/Re-manufacturer/
Final Manufacturer Name
Original Manufacturer Model Year
Date of Original Manufacture
Date of Last Changes

oU.S. Code

Has any alteration, modification, change, refurbishing, or addition of components been done in violation of Title 49, United States Code Chapter 301 Section 30122 b? / Yes No

oAxles

Original Gross Vehicle Weight Rating Lbs.
Present Gross Vehicle Weight Rating Lbs.
Original Gross Axle Weight Rating Front Lbs.
Original Gross Axle Weight Rating Rear Lbs.
Present Gross Axle Weight Rating Front Lbs.
Present Gross Axle Weight Rating Rear Lbs.

oWeights

Original Wet Curb Weight - Lbs.
(Measured with no passengers or driver and all reservoirs [including fuel tank] topped off)
Present Wet Curb Weight - Lbs.
(Measured with no passengers or driver and all reservoirs [including fuel tank] topped topped off)
Rear to Front Gross Axle Weight Ratio (in percentage) / /

oTires and Wheels

Front / Rear
Are the tire sizes and ratings different than original? / Yes No / Yes No
Are the wheel sizes and ratings different than original? / Yes No / Yes No
Front / Rear
Tire Size
Load Rating Code
Weight Rating Lbs.
Pressure for Required Load in PSI
Wheel Weight Rating
Maximum Wheel Air Pressure Rating
Weight per Tire with Vehicle Fully Loaded (calculated by multiplying 150 lbs. times the number of adults vehicle is capable of seating based on each 16 inches seat width available, plus 150 lbs. for driver, plus wet curb weight, with gross axle weight ratio factored)
Do the tires and wheels meet the standards set forth in 49 CFR 571.120? / Yes No

oBrake System

1.Brakes

Has the brake system been modified?
This includes, but is not limited to; drums/rotors, lining size or type, lines extended, other component parts changed or modified. / Yes No
If “Yes”, were the brakes tested to FMVSS 49 CFR 571.105 or 571.121 Standards after modifications on this vehicle or an exact like model? / Yes No
Front (inches) / Rear (inches)
Drum Diameter
Drum Surface Width
Rotor Diameter
Rotor Surface Width
2.Original Dimensions
  1. Present Dimensions

Front (inches) / Rear (inches)
Drum Diameter
Drum Surface Width
Rotor Diameter
Rotor Surface Width

4.Hydraulic Brake Systems

If equipped, has the hydraulic brake system been altered or modified?
This includes, but is not limited to; gauges, warning devices, warning statements, hydraulic brake fluid and reservoirs, brake assemblies and components, brake pedal, and brake light switch. / Yes No
If “Yes”, does/do the system(s) meet the standards set forth in 49 CFR 571.105? / Yes No
Does the hydraulic brake fluid meet the standards set forth in 49 CFR 571.116 for the current application? / Yes No

5.Brake Hoses

Have any brake hoses been changed, altered, or modified?
This includes, but is not limited to hoses, hose labeling, hose assemblies, brackets, and end fittings. / Yes No
If “Yes”, does/do the system(s) meet the standards set forth in 49 CFR 571.106? / Yes No
  • Controls and Displays

Have the driver controls and displays been altered or modified? / Yes No
If “Yes”, do the controls and displays meet the standards set forth in 49 CFR 571.101? / Yes No
  • Transmission Shift Lever Sequence, Starter Interlock,andTransmission Braking Effect

Have the transmission shift lever sequence, starter interlock, and transmission braking effect been altered/modified? / Yes No
If “Yes”, do all these items meet the standards set forth in 49 CFR 571.102? / Yes No

oWindshield Defrosting and Defogging Systems

Have the windshield defrosting and defogging system(s) been altered or modified? / Yes No
If “Yes”, does/do the system(s) meet the standards set forth in 49 CFR 571.103? / Yes No

oWindshield Wiping and Washing Systems

Have the windshield wiping and washing system(s) been altered or modified? / Yes No
If “Yes”, does/do the system(s) meet the standards set forth in 49 CFR 571.104? / Yes No

oLamps, Reflective Devices, and Associated Equipment

Have any lamps, reflective devices or assemblies been added, modified, or altered? / Yes No
If “Yes”, does/do the system(s) meet the standards set forth in 49 CFR 571.108? / Yes No
If “Yes”, are all lamps approved by the Automotive Manufacturers Equipment Compliance Agency, Inc.? / Yes No

oRear View Mirrors

Have any rear view mirrors been added, modified, or altered? / Yes No
If “Yes”, does/do the system(s) meet the standards set forth in 49 CFR 571.111? / Yes No

oHood Latch Systems

Has the hood latch system been modified or altered? / Yes No
If “Yes”, does/do the system(s) meet the standards set forth in 49 CFR 571.113? / Yes No

oAccelerator Control System

Has the accelerator control system been modified or altered?
This includes, but is not limited to levers, pedal, cables, rods, springs, brackets, cruise control (module, wiring, cables, vacuum components), associated switches, and associated sensors. / Yes No
If “Yes”, does/do the system(s) meet the standards set forth in 49 CFR 571.124? / Yes No

oWarning Devices

If the vehicle has a gross vehicle weight rating of greater than 10,000 lbs. has it been equipped with warning devices for preventing injuries due to rear end collisions? / Yes No
If “Yes”, does/do the system(s) meet the standards set forth in 49 CFR 571.125? / Yes No

oSteering Control Rearward Displacement

Has any alterations/modifications been made that may affect the function, physical or mechanical properties, elements, location or vital special clearances of the components or assemblies of the steering wheel, steering column and related hardware? / Yes No
If “Yes”, does the steering system now conform to all standards set forth in 49 CFR 571.204? / Yes No

oGlazing Materials

Has any glazing material been added, or any existing glazing material been altered or modified that such alterations/modifications will affect the function (including translucence), physical, mechanical, or chemical properties of the materials, monograms or the visibility of monograms? / Yes No
If “Yes”, do the materials now conform to all standards set forth in 49 CFR 571.205 and New York State Vehicle and Traffic Law Section 375? / Yes No
oOccupant Crash Protection
1.Restraints
Have any alterations/modifications been made to active or passive restraint systems (where required) that will affect the function, physical or mechanical properties or vital special clearances of these devices? / Yes No
If “Yes”, does/do the system(s) conform to standards set forth in 49 CFR 571.208? / Yes No
2.Seating Systems
Have any seats been altered, modified or added? / Yes No
If “Yes”, do all seats conform to the standards set forth in 49 CFR 571.207? / Yes No
What is the present seating capacity of the vehicle calculated at 16 inches width provided for each occupant?

3.Seat Belt Assemblies

Have any seat belt assemblies been added, modified, or altered? / Yes No
If “Yes”, does/do the assembly(s) conform to standards set forth in 49 CFR 571.209? / Yes No

4.Seat Belt Assembly Anchorages

Have any seat belt assembly(s) anchorage(s) been added, modified, or altered? / Yes No
If “Yes”, does/do the assembly(s) anchorages conform to standards set forth in 49 CFR 571.210? / Yes No

5.Child Restraint Systems

Have any child restraint system(s), assembly(s) been added, modified, or altered? / Yes No
If “Yes”, does/do the child restraint system(s) assembly(s) conform to standards set forth in 49 CFR 571.213? / Yes No

oBus Emergency Exits and Window Retention and Release

If the vehicle is defined as a bus in 49 CFR 571.3, has emergency exits and/or windows been added, altered or modified? / Yes No
If “Yes”, does/do the exit(s) and window(s) conform to standards set forth in 49 CFR 571.217? / Yes No

oFlammability of Interior Materials

Have occupancy compartment (interior) materials been added, modified, or altered? / Yes No
If “Yes”, does/do the interior material(s) conform to standards set forth in 49 CFR 571.302? / Yes No

If any of the above items have been modified or altered, attach a detailed description of these modifications/alterations.

CERTIFICATION: The information I have given on this application is true to the best of my knowledge. I certify that the vehicle is fully equipped as required by the New York State Vehicle and Traffic Law, and the New York State Transportation Law.
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IMPORTANT: Making a false statement in any application or in any proof or statements in connection with it, or deceiving or substituting in connection with this application, is a misdemeanor under Section 145.5 of the Transportation Law, and may also result in non-issuance or removal of a certificate of inspection, or the revocation or suspension of the registration pursuant to regulations established by the Commissioner. The Department makes no representation that it will issue a certificate inspection until the Commissioner is satisfied that the applicant is entitled to a certificate. Pending review of this application, neither the Commissioner of the Department of Transportation nor any of his or her employees, deputies or agents assumes any liability or responsibility for construction or modifications performed, improvements made or work done to the vehicle referenced in this application.