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Box 68674 • Harrisburg, PA 17106-8674  \n| A | CERTIFICATION: THIS STATEMENT IS UNACCEPTABLE IF INSURANCE LAPSE IS GREATER THAN 30 DAYS. ALL INFORMATION MUST BE COMPLETED BY THE VEHICLE OWNER ONLY. |  |  |  |\n| --- | --- | --- | --- | --- |\n|  | I,   , hereby state that I did not operate or permit operation of the following Print Name\u003Cbr>motor vehicle(s) between  / /  to  / /  due to lapse in insurance coverage.\u003Cbr>Insurance Cancellation Date Insurance Replacement Date |  |  |  |\n| B | APPLICATION INFORMATION |  |  |  |\n|  | Last Name (or Full Business Name) First Name Middle Name PA DL/Photo ID\\# Date of Birth Telephone Number\u003Cbr>or Bus. ID\\# |  |  |  |\n|  | Co-Owner Last Name First Name Middle Name PA DL/Photo ID\\# Date of Birth Telephone Number\u003Cbr>or Bus. ID\\# |  |  |  |\n| C | VEHICLE(S) INFORMATION |  |  |  |\n|  | Title Number | Registration Plate Number | Vehicle Identification Number | Make |\n|  | Title Number | Registration Plate Number | Vehicle Identification Number | Make |\n|  | Title Number | Registration Plate Number | Vehicle Identification Number | Make |\n|  | Title Number | Registration Plate Number | Vehicle Identification Number | Make |\n|  | Title Number | Registration Plate Number | Vehicle Identification Number | Make |\n| D | APPLICANT SIGNATURE |  |  |  |\n|  | WARNING: Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500 .00 and/or imprisonment up to one year (18 Pa.C.S. Section 4904[b]) .\u003Cbr>Signature of Owner or Authorized Signer Date\u003Cbr>Signature of Co-Owner/Title of Authorized Signer Date |  |  |  |\n\nINSTRUCTIONS  \nSend the completed certification to PennDOT at:  \nMailing Address: Bureau of Motor Vehicles, PO Box 68674, Harrisburg, PA 17106-8674  \nFax: (717) 772-1550  \nEmail: [FRInsurance@pa.gov](FRInsurance@pa.gov).  \nVisit [us at www.pa.gov/dmv or call](us at www.pa.gov/dmv or call) us at 717-412-5300. TTY callers—please dial 711 to reach us.","cbCaitorHbcZPWRL","https://ap.wps.com/l/cbCaitorHbcZPWRL","pdf",91904,"English","# Instructions\n## Submission contacts","[{\"question\":\"What does the statement of non-operation certify?\",\"answer\":\"It certifies that the vehicle owner did not operate, and did not permit operation of the listed vehicle(s), due to a lapse in insurance coverage.\"},{\"question\":\"What is the deadline limitation related to insurance lapse?\",\"answer\":\"The statement is unacceptable if the insurance lapse is greater than 30 days.\"},{\"question\":\"How should the completed certification be submitted?\",\"answer\":\"Send it to PennDOT/Bureau of Motor Vehicles at the provided mailing address, or submit by fax, email, or phone contact; TTY callers should dial 711.\"}]","STATEMENT OF NON-OPERATION OF VEHICLE(S) - Certification form | PDF",1789869764]