OREGON DEPARTMENT OF TRANSPORTATION MOTOR CARRIER TRANSPORTATION DIVISION 3930 FAIRVIEW INDUSTRIAL DRIVE SE SALEM OR 97302-1166 SEE INSTRUCTIONS ON BACK RESET PRINT ANNUAL MILEAGE REPORT FOR OPERATIONS EXEMPT UNDER ORS 825.017 NAME/ENTITY OPERATIONS FROM: ADDRESS ACCOUNT NUMBER JANUARY 1 - DECEMBER 31, 20 CITY STATE ZIP IDENTIFY THE SECTION OF OREGON REVISED STATUTE (ORS) 825.017 THAT QUALIFIES YOUR OPERATIONS AS EXEMPT FROM ORS CHAPTER 825: TELEPHONE (INCLUDE AREA CODE) VEHICLE MILEAGE AND WEIGHT CLASS INFORMATION B A LICENSE PLATE NUMBER STATE/ PROVENCE C REGISTERED WEIGHT Certification: I hereby certify that this report is correct. ANNUAL ODOMETER READINGS D BEGINNING E ENDING GRAND TOTAL SIGNATURE OF REPRESENTATIVE PRINTED NAME TITLE DATE FORM 735-9948 (6-14) F G TOTAL MILES OPERATED TOTAL OREGON MILES INSTRUCTIONS FOR COMPLETING THE ANNUAL MILEAGE REPORT FOR EXEMPT OPERATIONS Oregon Revised Statute (ORS) 825.018 requires all owners or operators of vehicles exempt from the provisions of ORS chapter 825 by ORS 825.017 to file an annual report with the Department of Transportation showing the miles of travel by each vehicle. Reporting Period: In the upper right hand corner of the form, identify the year for which you are reporting mileage. This report will cover operations for the prior calendar year. This report must be filed no later than the 31st day of March, following the year in which the operations occurred. Enter the name, address, telephone number, and account number, in the specified areas. Identify the type of operation that qualifies the vehicles as exempt from ORS 825 on the line provided. A list of exemptions can be found online in section 825.017 at http://www.oregon.gov/ODOT/DMV/docs/vcb/vcb825.pdf VEHICLE MILEAGE AND WEIGHT CLASS INFORMATION: Column A: Enter the license plate number of the power unit for which you are reporting. Include all vehicles operated under exempt status during the reporting period. Column B: Enter the state or province that issued the license plate. Column C: Enter the registration weight of the vehicle. Column D: Enter the beginning odometer reading for each vehicle as of January 1 of the year for which you are reporting. Column E: Enter the ending odometer reading for each vehicle as of December 31 of the year for which you are reporting. Column F: Enter the total miles operated for each vehicle (Column E minus Column D). Column G: Enter the total miles operated on Oregon public roads for each vehicle. Grand Total: Enter the total miles tallied for columns F and G individually. Certification: Sign and date the report. Print the name and title of the representative. Maintain a copy for your records. Mail or fax your completed report to: ODOT Motor Carrier Transportation Division 3930 Fairview Industrial Dr SE Salem OR 97302-1166 Phone: (503) 378-6207 Fax: (503) 373-1940
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