NHTSA Form 1484 Statement of Conformity

National Highway Traffic Safety Administration

Our Mission: Save lives, prevent injuries, reduce vehicle-related crashes

Statement of Conformity

(April 2013)

OMB No. 2127-0002

Exp. 04-30--2017

Import and Certification Division 1200 New Jersey Ave., SE, Room W45-205

Washington, DC 20590

Fax: 202-493-0073

Website Address: www.nhtsa.dot.gov/cars/rules/import/

RI Name

Model Year

Customs Entry #

RI #

Address Where Vehicle Was Conformed

Make/Model

VIN

Entry Date

Port Code

Manufacture Date (Mo/Yr)

Service Insurance Policy #

Odometer ( ) miles ( ) km

Insurer

Address Where Vehicle Can Be Inspected

Vehicle Type

Is this your initial certification for this make, model, and model

Vehicle Eligibility #

year?

Yes No

No.

FMVSS

O

M

N

No.

FMVSS

O

M

N

No.

FMVSS

O

M

N

101	Controls and Displays	129	Non-Pneumatic Tires	220	School Bus Rollover Protection
102	Transmission Shift Sequence	131	School Bus Pedestrian Safety	221	School Bus Joint Strength
103	Windshield Defrosting, Defogging	135	Light Vehicle Brake Systems	222	School Bus Seating/Crash Protection
104	Windshield Wiping and Washing	138	Tire Pressure Monitoring System	223	Rear Impact Guards
105	Hydraulic and Electric Brake Systems	139	New Pneumatic Radial Tires	224	Rear Impact Protection
106	Brake Hoses	201	Occupant Protection Interior Impact	225	Child Restraint Anchorage Systems
108	Lamps, Reflective Devices	202	Head Restraints	226	Ejection Mitigation
109	New Pneumatic Tires	203	Impact Protection From Steering	301	Fuel System Integrity
110	TIre Selection and Rims	204	Steering Control Rearward	302	Flammability of Interior Materials
111	Review Mirrors	205	Glazing Materials	303	Fuel System Integrity of CNG Vehicles
113	Hood Latch System	206	Door Locks and Retention Components	304	CNG Fuel Container Integrity
114	Theft Protection	207	Seating Systems	305	Electric-Powered Vehicles
116	Motor Vehicle Brake Fluids	208	Occupant Crash Protection	401	Internal trunk release
118	Power Operated Window Systems	209	Seat Belt Assemblies	404	Platform Lift Installations
119	New Pneumatic Tires	210	Seat Belt Assembly Anchorages	500	Low Speed Vehicles
120	TIre Selection and Rims	212	Windshield Mounting		49 CFR
121 122	Air Brake Systems Motorcycle Brake Systems	213 214	Child Restraint Systems Side Impact Protection	565	VIN Requirements
123	Motorcycle Controls and Displays	216	Roof Crush Resistance	567	Certification
124 126	Accelerator Control Systems Electronic Stability Control	217 219	Bus Exits, Window Retention, Release Windshield Zone Intrusion	581	Bumper Standard

120	TIre Selection and Rims	212	Windshield Mounting
121	Air Brake Systems	213	Child Restraint Systems
122	Motorcycle Brake Systems	214	Side Impact Protection
123	Motorcycle Controls and Displays	216	Roof Crush Resistance
124	Accelerator Control Systems	217	Bus Exits, Window Retention, Release
126	Electronic Stability Control	219	Windshield Zone Intrusion

I state and provide substantiation that (check only one):

The vehicle is not subject to any safety recalls as of the time of such certification, or

All noncompliances and defects that are the subject of safety recalls have been remedied.

I certify that (check only one):

The vehicle is not required to comply with the parts marking requirements of the Theft Prevention Standard "Part 541", or

The vehicle, as manufactured or as modified prior to importation, complies with those parts marking requirements.

I certify that (check only one):

I know that the vehicle I am certifying conforms with all applicable Federal motor vehicle safety and bumper standards because I personally witnessed each modification performed on the vehicle to effect compliance, or

I know that the vehicle I am certifying conforms with all applicable Federal motor vehicle safety and bumper standards because the person who performed the necessary modifications to the vehicle is an employee of the above named RI and has provided full documentation of the work that I have reviewed, and I am satisfied that the vehicle as modified complies.

I certify that noncompliant motor vehicle equipment items that were removed from this imported vehicle in the course of performing conformance modifications have been (check only one):

Destroyed,

Exported, or Not Applicable.

RI or Designated Representative Signature:

* (*Must be original, not machine stamp, etc.)

Print Name:

Designation: ^Date:

PAPERWORK REDUCTION ACT STATEMENT: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2127-0002. The information collected on this form is necessary to obtain a letter from NHTSA releasing the DOT Conformance bond furnished on form HS-474 to ensure that an imported nonconforming vehicle is brought into conformity with all applicable Federal motor vehicle safety standards within 120 days from its date of importation, or is exported from or abandoned to, the United States. The information is used to verify that the vehicle conforms to, or has been brought into conformity with, all applicable Federal motor vehicle safety and bumper standards. We estimate that it will take approximately 30 minutes to complete the form. The information collected is mandatory under 49 U.S.C. § 30141(d) and 49 CFR 49 CFR 591.5(f). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Room W45-205, Washington, DC, 20590.

NHTSA Form 1484