California Code of Regulations
Title 13 - Motor Vehicles
Division 3 - Air Resources Board
Chapter 13 - Voluntary Accelerated Vehicle Retirement Enterprises
Article 1 - Voluntary Accelerated Light-Duty Vehicle Retirement Enterprises
Appendix A

Universal Citation: 13 CA Code of Regs A
Current through Register 2024 Notice Reg. No. 38, September 20, 2024

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:___________________________

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).

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