Cal. Code Regs. Tit. 13, div. 3, ch. 13, art. 1, app A

Current through Register 2024 Notice Reg. No. 50, December 13, 2024

Appendix A

VEHICLE FUNCTIONAL AND EQUIPMENT ELIGIBILITY INSPECTION FORM

Legal Owner:___________________________	Address:___________________________
City:___________________________	Zip:___________________________
VIN:___________________________	License Number:___________________________
Make:___________________________	Model:___________________________
Model Year:___________________________	Odometer Reading:___________________________

VEHICLE QUALIFICATION
Vehicle within 61-90 days of next scheduled Smog Check:	yes	no	2602(c)
If yes, vehicle failed next scheduled Smog Check:	yes^*	no
Vehicle registered in District for at least 24 months:	yes	no^*	2603(a)(2)
Vehicle on BAR repair cost waiver	yes^*	no	2603(a)(4)
Vehicle on BAR economic hardship extension	yes^*	no	2603(a)(4)
Vehicle within 60 days of next scheduled Smog Check:	yes	no	2603(a)(5)
If yes, vehicle passed next scheduled Smog Check:	yes	no^*
The vehicle has been tampered with:	yes^*	no	2603(a)(7)
The vehicle has been driven to the inspection site	yes	no^*	2603(b)(1)
^* Vehicle is not qualified for the VAVR program.

EQUIPMENT ELIGIBILITY		The following shall be present and in place:			2603(b)(3)
All doors	yes	no^*	Hood	yes	no^*
Dashboard	yes	no^*	Driver's seat	yes	no^*
One bumper	yes	no^*	All side and/or quarter panels	yes	no^*
Exhaust system	yes	no^*	One headlight	yes	no^*
One taillight	yes	no^*	One brake light	yes	no^*
One side window	yes	no^*	Interior pedals operational	yes	no^*

FUNCTIONAL ELIGIBILITY	The following shall be completed:		2603(b)(4)
Vehicle starts using keyed ignition		yes	no^*
Vehicle starts without the use of starting fluids or external battery		yes	no^*
Vehicle driven forward for a minimum of 25 feet		yes	no^*
Vehicle driven in reverse for a minimum of 25 feet		yes	no^*
^* Vehicle is not eligible for the VAVR program.

INSPECTOR CERTIFICATION: (Check correct boxes.) I certify that this vehicle has ( passed not passed) both the functional and equipment eligibility inspections and ( is is not) eligible for acceptance into the VAVR program pursuant to California Code of Regulations, Title 13, Sections 2602 and 2603.

Printed Name:___________________________	Date:___________________________
Signed:___________________________

The following should be completed if the vehicle is eligible for acceptance into a VAVR program.

OWNER ACCEPTANCE: I accept receipt of this CERTIFICATION of eligibility into a VAVR program. I agree not to alter the vehicle's equipment or functionality from that presented to the inspector. I agree to maintain the vehicle's condition and registration until the vehicle is retired.

Printed Name:___________________________	Date:___________________________
Signed:___________________________

Cal. Code Regs. Tit. 13, div. 3, ch. 13, art. 1, app A

1. New appendix A filed 12-8-99; operative 1-7-2000 (Register 99, No. 50).
2. Repealer and new appendix A filed 7-13-2007; operative 8-12-2007 (Register 2007, No. 28).