Statement of Facts

H. APPLICANT’S SIGNATURE
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
PRINTED LAST NAME FIRST NAME MIDDLE NAME DAYTIME PHONE NUMBER
SIGNATURE DATE
F. STATEMENT FOR NAME CHANGE OR CORRECTION (OWNERSHIP CERTIFICATE REQUIRED)
Please print
I, _______________________________ and _______________________________ are one and the same person.
My name is misspelled. Please correct it to: _________________________________________________________
I am changing my name from ________________________________ to __________________________________
E. STATEMENT FOR VEHICLE BODY CHANGE (OWNERSHIP CERTIFICATE REQUIRED)
The current market value of the vehicle or vessel is: $________________ .
Changes were made at a cost of $________________ on this date ________________ .
This is what I changed: Check all that apply:
Unladen Weight changed because __________________ (Public Weighmaster Certi cate is required. Exception: Trailers)
Motive Power changed from ________________ to ________________ .
Body Type changed from ________________ to ________________ .
Number of Axles changed from ________________ to________________ .
REG 256 (REV. 1/2007) WWW
G. STATEMENT OF FACTS
I, the undersigned, state:
STATEMENT OF FACTS
Complete the appropriate section(s) in full (including vehicle description) and sign Section H.
LICENSE PLATE/CF NUMBER VEHICLE/VESSEL ID NUMBER YEAR/MAKE
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