Law Enforcement Certification

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State of Illinois
Office of the Secretary of State
Law Enforcement Certification
VEHICLE INFORMATION
Name of Owner(s):
1. ______________________________________________________________________
Last
First
Middle Initial
2. ______________________________________________________________________
Last
First
Middle Initial
Address of Owner:
______________________________________________________________________
______________________________________________________________________
City
State
ZIP
I hereby certify and affirm that I have made a physical inspection of the vehicle and the information below is true and
correct. Form to be completed by a law enforcement officer only.
Vehicle Description:
______________________________________________________________________
Year
Make & Model
______________________________________________________________________
Body Style
Cylinders
Horsepower
______________________________________________________________________
Vehicle Identification Number
(For Second Stage
______________________________________________________________________
Vehicle Use Only)
Year
Make
Model
Body Style
______________________________________________________________________
Vehicle Identification Number
CERTIFICATION INFORMATION
(Please Type or Print)
Name of Law
Enforcement Agency:
______________________________________________________________________
Address:
______________________________________________________________________
Street
______________________________________________________________________
City, State, ZIP
Signature of Officer
Making Inspection:
______________________________________________________________________
Printed by authority of the State of Illinois. March 2015 – 1 – VSD-43.6

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