PennDOT - Self-Certification of Vehicle(s) Owned/Operated - LifeSafer 2026

1. Click ‘Get Form’ to open the PennDOT - Self-Certification of Vehicle(s) Owned/Operated - LifeSafer in our editor.
2. Begin with Section A by entering your full name, driver license number, and address. Ensure all information is typed or printed clearly in blue or black ink.
3. Move to Section B where you will list all vehicles owned or permitted to operate. Fill in the plate number, title number, VIN, and year/make for each vehicle. If applicable, indicate if a violation occurred prior to 10/1/03.
4. In Section C, check the appropriate box regarding ownership status. Print your name, sign in ink, and date the form. If applying for a hardship exemption, ensure you attach your income tax return.
5. Section D must be completed by the vendor after verifying the information from Section B. They will also sign and date this section before submission.

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