Vehicle Inspection Form Ky

COMMONWEALTH OF KENTUCKY

VEHICLE INSPECTION RECORD (TC 96-182)

INSTRUCTIONS: This form is intended to document the physical inspection of a vehicle as required by the Kentucky Transportation Cabinet for purposes of titling and registration. All fields must be completed in full.

I. VEHICLE IDENTIFICATION

• Make: __________________________
• Model: __________________________
• Year: __________________________
• Vehicle Identification Number (VIN): __________________________________
• Body Type: __________________________
• Odometer Reading: __________________________
• Primary Color: __________________________
• Fuel Type: __________________________

II. OWNER/APPLICANT INFORMATION

• Legal Name: ________________________________________________
• Residential Address: ________________________________________________
• City: __________________________ State: KY Zip Code: __________
• Contact Phone: (____) ____-_______

III. INSPECTION FINDINGS

The undersigned official hereby certifies that they have physically inspected the aforementioned vehicle.

1. VIN Verification: [ ] Matches Certificate of Title / [ ] Does Not Match / [ ] VIN Plate Missing
2. Odometer Integrity: [ ] Operable / [ ] Inoperable
3. Safety Equipment Inspection:
   • Headlights/Taillights: [ ] Functional / [ ] Non-Functional
   • Turn Signals: [ ] Functional / [ ] Non-Functional
   • Braking System: [ ] Functional / [ ] Non-Functional
   • Tire Condition: [ ] Compliant / [ ] Non-Compliant

Additional Comments/Notations: ______________________________________________________________________ ______________________________________________________________________

IV. CERTIFICATION AND SIGNATURES

DECLARATION OF INSPECTOR: I, the undersigned, affirm that I have conducted a visual inspection of the vehicle described herein. I certify that the information provided on this form is true, accurate, and complete to the best of my professional knowledge.

Inspector Name (Printed): ______________________________________ Agency/Badge ID: ______________________________________ Date of Inspection: _____ / _____ / 20_____

Signature of Inspector: _________________________________________________

AFFIDAVIT OF OWNER/APPLICANT: I hereby certify that I am the owner or authorized agent of the vehicle described above and that the information submitted is accurate under penalty of perjury.

Signature of Owner/Applicant: _________________________________________________ Date: _____ / _____ / 20_____

V. FOR OFFICE USE ONLY

• County of Inspection: __________________________
• Date Processed: _____ / _____ / 20_____
• Clerk Initials: __________