Form 96-0284 "Alternative Fuel Withdrawal" - Arizona

What Is Form 96-0284?

This is a legal form that was released by the Arizona Department of Transportation - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2009;
  • The latest edition provided by the Arizona Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 96-0284 by clicking the link below or browse more documents and templates provided by the Arizona Department of Transportation.

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Download Form 96-0284 "Alternative Fuel Withdrawal" - Arizona

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ALTERNATIVE FUEL WITHDRAWAL
Clear
www.azdot.gov
96-0284 R10/09
Vehicle Identification Number
Year
Make
License Plate
I certify that the vehicle above was registered as an alternative fuel vehicle and that I have removed the vehicle’s
alternative fuel storage tanks and placards. I agree to pay the full vehicle license tax and registration fees for the
current registration year, due for a non-alternative fuel vehicle. I agree to defend, hold harmless and indemnify the
Arizona Department of Transportation and the Arizona Department of Environmental Quality, and any of its officers,
employees, agents or contractors, from all actions brought or damages alleged by reason of these decisions on my
part.
Owner Name (first, middle, last, suffix)
Signature
Mailing Address
City
State
Zip
Notary or MVD Agent Signature
Acknowledged before me this date.
Date
County
State
Commission Expires
Requirements
Once the alternative fuel storage tanks/cylinders and placards have been completely removed, you must visit an
MVD or authorized third party office to remove the alternative fuel designation and re-register as a gasoline
powered vehicle. You must submit the following:
• This form, properly notarized, or witnessed by an MVD agent
• The alternative fuel plates (or a pay a $5.00 lost plate fee)
• Proof of compliance with emissions testing requirements (A Restricted Use 3-Day Permit can be purchased online
at www.servicearizona.com to lawfully operate the vehicle for emissions testing purposes). See below for
additional emissions testing information.
Any remaining allowable fees will be credited and a new registration document and license plate will be issued for
the gasoline powered vehicle.
Additional Emissions Testing Information
Please note that model 1996 and newer light duty vehicles will receive an On-Board Diagnostic inspection instead
of the tailpipe emissions inspection that the alternative fuel vehicle received. It is suggested that you have the
On-Board Diagnostic system checked, prior to taking the vehicle for an emissions inspection, to insure that it is
operating properly.
For technical assistance, please call the Arizona Department of Environmental Quality at 602-771-3954.
MVD Use
New Plate Issued
MVD Agent
Office
Issue Date
ALTERNATIVE FUEL WITHDRAWAL
Clear
www.azdot.gov
96-0284 R10/09
Vehicle Identification Number
Year
Make
License Plate
I certify that the vehicle above was registered as an alternative fuel vehicle and that I have removed the vehicle’s
alternative fuel storage tanks and placards. I agree to pay the full vehicle license tax and registration fees for the
current registration year, due for a non-alternative fuel vehicle. I agree to defend, hold harmless and indemnify the
Arizona Department of Transportation and the Arizona Department of Environmental Quality, and any of its officers,
employees, agents or contractors, from all actions brought or damages alleged by reason of these decisions on my
part.
Owner Name (first, middle, last, suffix)
Signature
Mailing Address
City
State
Zip
Notary or MVD Agent Signature
Acknowledged before me this date.
Date
County
State
Commission Expires
Requirements
Once the alternative fuel storage tanks/cylinders and placards have been completely removed, you must visit an
MVD or authorized third party office to remove the alternative fuel designation and re-register as a gasoline
powered vehicle. You must submit the following:
• This form, properly notarized, or witnessed by an MVD agent
• The alternative fuel plates (or a pay a $5.00 lost plate fee)
• Proof of compliance with emissions testing requirements (A Restricted Use 3-Day Permit can be purchased online
at www.servicearizona.com to lawfully operate the vehicle for emissions testing purposes). See below for
additional emissions testing information.
Any remaining allowable fees will be credited and a new registration document and license plate will be issued for
the gasoline powered vehicle.
Additional Emissions Testing Information
Please note that model 1996 and newer light duty vehicles will receive an On-Board Diagnostic inspection instead
of the tailpipe emissions inspection that the alternative fuel vehicle received. It is suggested that you have the
On-Board Diagnostic system checked, prior to taking the vehicle for an emissions inspection, to insure that it is
operating properly.
For technical assistance, please call the Arizona Department of Environmental Quality at 602-771-3954.
MVD Use
New Plate Issued
MVD Agent
Office
Issue Date