New York State Department of Motor Vehicles CERTIFICATE OF REMOVAL OF VEHICLE FROM UNITED STATES AND CANADA Please prepare this form in duplicate, and present both copies with the vehicle registration. The registration will be returned to you with one copy of this form. Name Vehicle I.D. Number Number and Street Year City or Town Make Body Type State Plate No. Zip Code Sticker No. Expiration Date In accordance with Section 318.1(d) of the Vehicle and Traffic Law, I apply for exemption from the Motor Vehicle Financial Security Act. I certify that: the liability insurance on the vehicle described above has not been, and will not be, terminated or lapsed prior to removal; and that the vehicle has already been removed from the United States and Canada for the purpose of international traffic, or that it will be removed for such purpose before _____________________________. I agree to notify the Commissioner of Motor Vehicles immediately upon return of the vehicle to the United States or Canada, and to provide new proof of insurance coverage, together with the vehicle registration. Approved by (MV Staff Member) Signature of Registrant Motor Vehicles Office Date www.dmv.ny.gov FS-113 (3/11) cut along dotted line ........... cut along dotted line ........... cut along dotted line ........... New York State Department of Motor Vehicles CERTIFICATE OF REMOVAL OF VEHICLE FROM UNITED STATES AND CANADA Please prepare this form in duplicate, and present both copies with the vehicle registration. The registration will be returned to you with one copy of this form. Name Vehicle I.D. Number Number and Street Year City or Town Make Body Type Plate No. State Sticker No. Zip Code Expiration Date In accordance with Section 318.1(d) of the Vehicle and Traffic Law, I apply for exemption from the Motor Vehicle Financial Security Act. I certify that: the liability insurance on the vehicle described above has not been, and will not be, terminated or lapsed prior to removal; and that the vehicle has already been removed from the United States and Canada for the purpose of international traffic, or that it will be removed for such purpose before _____________________________. I agree to notify the Commissioner of Motor Vehicles immediately upon return of the vehicle to the United States or Canada, and to provide new proof of insurance coverage, together with the vehicle registration. Approved by (MV Staff Member) Motor Vehicles Office FS-113 (3/11) Signature of Registrant Date www.dmv.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com