State of Fact for a Stored Vehicle

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STATEMENT OF FACT FOR A STORED VEHICLE I, am the registered owner of the following described vehicle as indicated on the records of the Director of Finance of the County of Hawaii, State of Hawaii: License Plate Number: Vehicle Identification Number: The above described vehicle has been removed from any public highway or other public property and will be kept in storage on private property located at: Street Address City&State Zip Code I am surrendering the current certificate of registration, license plates and emblem for the vehicle as evidence of the fact that the said vehicle will not be operated on any public highway or public property. In accordance with Section 249-5, Hawaii Revised Statutes, I understand that the license plates for any vehicle whose registration has expired will be disposed and the owner shall be required to purchase new license plates and a new emblem upon removing the vehicle from storage. In addition, I must present the stamped certificate of registration, a new vehicle inspection certificate, if expired, and pay the required taxes and fees as a condition precedent to the removal of the vehicle from storage. Dated: (Signature of Registered Owner) (Printed Name of Registered Owner Street or P.O. Box Address City,State and Zip Code Created 08/07/09 Master Stmt of Fact-STORED.)tbwai'i County is an Equal Opportunity Provider and Employer Revised 9/4/2009