BOAT 111, Vessel Verification

STATE OF CALIFORNIA VESSEL VERIFICATION

® BOATS DEPARTMENT OF MOTOR VEHICLES A Public Service Agency THIS FORM MUST BE COMPLETED IN FULL BOAT TYPE VESSEL CF NUMBER STATE EXP. YEAR

VESSEL BUILDER YEAR BUILT LENGTH JON KAYAK PONTOON RUNABOUT CENTERBOARD KEEL BOAT FT . IN HULL IDENTIFICATION NUMBER (HIN) ON VESSEL HYDROPLANE BASS BOAT CANOE YACHT HOUSEBOAT

() VESSEL TYPE () PROPULSION () HULL MATERIAL () FUEL A - Amphibious A - Aux/Sail D - Diesel A - Aluminum HIGH AIRBOAT CABIN DAY B - Barge H - Hand Prop C - Cement PERFORMANCE CRUISER CRUISER C - Cruiser I - Inboard P - Plastic/ G - Gasoline H - House boat J - Jet Fiberglass I - Inflatable N - Inb-Outb S - Steel X - Other TYPE PROPULSION K - Kayak/Canoe O - Outboard W - Wood O - Row boat S - Sail only X - Other INBOARD INBOARD R - Runabout X - Other OUTBOARD S - Sailboat X - Other

VESSEL COLOR(S) OUTDRIVE OUTBOARD SAIL SAIL SAIL JET OUTBOARD INBOARD

HIN GENERAL LOCATION: ATTACHED BY: HULL SHAPES Transom - Outside Not visible Adhesive Transom - Inside Screws Not applicable CATAMARAN DEEP V FLAT PONTOON ROUND SEMI V TRI TUNNEL Other: Round rivets Other: BOTTOM TYPE: Metal Plate Stamped Carved EXAMPLE Burned Embossed/Imbedded Other: HIN (Hull Identification Number) BOW ENGINE MANUFACTURER:

A B C 4 5 6 7 8 A 4 8 4 LENGTH ENGINE NO.: OUTDRIVE NO.: PORT BEAM None—new engine or case supplement # Manufacturer's Hull Month/Year Model HIN/ENGINE NO. STARBOARD I.D. Code (MIC) Serial of Year HIN ENG HIN ENG HIN ENG Number Manufacture Appears okay Missing See REMARKS STERN TRANSOM Altered/Tampered Cannot locate Needs CFZ assignment Jan - A June - F Nov - K Illegible/Damaged None-Newly built Feb - B July - G Dec - L HULL IDENTIFICATION NUMBER IN THIS SUPPORTING DOCUMENTS: Mar - C Aug - H LOCATION Agree with HIN None No HIN on documents Apr - D Sept - I Disagree with HIN See REMARKS May - E Oct - J APPROXIMATE VESSEL VALUE U.S. Coast Guard standards for hull identification numbers were established in 1972 and made mandatory on Aug. 1 1984. (no uniform hull identification numbers prior to 1972).

I certify (or declare) under penalty of perjury under the laws of the State of California that the REMARKS foregoing is true and correct. I further certify that I examined the vessel described above and find the description of the vessel to be as indicated. VERIFIER (PRINT NAME) TITLE/BADGE/ID NO.

ADDRESS CITY STATE

VERIFIED AT CITY STATE Above address Other (specify) DATE VERIFIER'S SIGNATURE DAYTIME TELEPHONE NO. X ( ) EMPLOYER DMV Vessel Verifier Other (specify)

BOAT 111 (REV. 5/2014) WWW