INCOME-BASED CLEAN AIR VEHICLE

DECAL PROGRAM APPLICATION

Effective January 1, 2020, a vehicle that was previously issued a Clean Air Vehicle (CAV) decal may be re-issued a CAV decal
if all of the following conditions are met:
• The vehicle and vehicle owner were not issued a CAV decal prior to January 2017.
(California Vehicle Code (CVC) §5205.5)
• The registered owner name(s) matches Department of Motor Vehicles’ (DMV) records.
• The applicant’s total annual household income is at or below $65,777 (80% of the state median income as designated by the
California Department of Housing and Community Development; amount subject to change).
Household income information provided as part of an application for CAV decals under the Income-Based Clean Air Vehicle
Decal Program is subject to review by the Franchise Tax Board or other income verification entity.
This form must be submitted with a completed Clean Air Vehicle Decal Application (REG 1000) form and the $22 CAV Decal fee
(check or money order, do not send cash) to the address listed on the REG 1000. Illegible, incomplete and/or unsigned forms
will be returned. Decals issued under this program will be valid until January 1, 2024.
Note: If this vehicle has never been issued a CAV decal, do not use this form; complete a REG 1000 form only and submit
with the CAV decal fee to the address listed on the form.
If a CAV decal was previously issued for this vehicle under your name, you are not eligible to participate in the Income-Based
Clean Air Vehicle Decal Program.

How to complete the Income-Based Clean Air Vehicle Decal Application, REG 1000 IB form:
The vehicle must be registered in the applicant’s name. If this is a recently acquired vehicle, the transfer of ownership (from
dealership or private party) must be completed before the application can be submitted. You will receive a registration card from
DMV once the transfer of ownership is complete. The address on the application must match the address on the vehicle
registration card.
• Ensure your vehicle is on the CARB eligibility carpool sticker list by checking CARB’s website arb.ca.gov, Carpool Stickers
or calling 1-800-242-4450.
• Complete an Application for Clean Air Vehicle Decal (REG 1000) form, in Section 2:
– Check the “Transfer to new owner” box.
– Check the “Income-Based CAV Decal Program” box.
– For assistance on how to complete the REG 1000, go to dmv.ca.gov, Clean Air Vehicle Decals, High Occupancy Ve-
hicle Lane Usage webpage, Frequently Asked Questions.
• Complete Section 1 of the REG 1000 IB with the applicant’s name and address. All information must match the REG 1000.
– Check the appropriate address box for “Address Used For Your Most Recent Tax Filing”.
– Complete the field for the last four of your social security number (SSN).
– Complete the field for your California driver license (DL) or identification card (ID) number.
– Complete the field for your DL/ID issue date, found in the lower right corner of your card, under “ISS”.
• Complete Section 2 by listing all members of your household, age 17 and older. Your name and income are first on the
list. You may attach an additional form if there are more than four (4) members in your household.
– Total all Annual Income amounts.
• Complete Section 3 by providing all vehicle information. Information must match the REG 1000.
• Complete Section 4 by reading all important information, printing your name and telephone number, and signing the
application. An original signature is required.
• Submit the completed REG 1000 IB application, completed REG 1000 application, and $22 decal fee (do not send
cash) to the address shown on the REG 1000 form.

Privacy Statement: DMV uses personal information only for the specified purpose, or purposes consistent with those purposes,
unless DMV obtains your consent, or authorized by law or regulations. DMV’s Privacy Policy is located at dmv.ca.gov under the
“Privacy Policy” link at the bottom of the page.

REG 1000 IB (NEW 1/2020) DMVWeb

MAILING ADDRESS CITY STATE ZIP CODE

RESIDENCE ADDRESS (IF DIFFERENT FROM MAILING ADDRESS) CITY STATE ZIP CODE

ADDRESS USED FOR YOUR MOST RECENT TAX FILING:

……
Mailing ……
Residence ……
Other, please specify below:
ADDRESS CITY STATE ZIP CODE

LAST 4 DIGITS OF SSN DATE OF BIRTH (MM/DD/YYYY) DRIVER LICENSE OR ID CARD NUMBER DRIVER LICENSE OR ID CARD ISSUE DATE (ISS)

SECTION 2 — HOUSEHOLD INCOME INFORMATION (Subject to verification)

This application requires the disclosure of the annual income of all members of the household, age 17 and older, who reside
together and share common living expenses regardless if they are related. This includes but is not limited to a spouse, significant
other, family member(s), and/or roommate(s). Examples of income include wages, unemployment, Social Security, public
assistance, pensions, alimony and/or any other miscellaneous sources of income.
Enter the name and annual income for each household member age 17 or older, including yourself (attach an additional form if
there are more than 4 members in your household):

Household Member True Full Name Annual Income

1 (applicant) $

2 (Applicant) $

3 (Applicant) $

4 (Applicant) $

Total Annual Household Income $ 0.00

SECTION 3 — VEHICLE INFORMATION (Must match REG 1000)

YEAR MAKE MODEL DATE PURCHASED

SECTION 4 — CERTIFICATION

I am eligible for a Clean Air Vehicle (CAV) decal pursuant to the requirements in California Vehicle Code (CVC) §5205.2.
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and
correct. I understand that DMV may verify the information on this application with the Franchise Tax Board or other
income verification entity, and hereby authorize the Franchise Tax Board, or other verification entity, to do so upon
request by DMV. I also agree voluntarily to submit personal identification information for the purposes of processing
my CAV decal application and I consent to my personal information being shared for income verification purposes.
I understand that DMV may deny this application or revoke the CAV decals issued to me pursuant to this application
based on income verification results.
PRINTED NAME OF REGISTERED OWNER DAYTIME TELEPHONE NUMBER

( )
SIGNATURE OF REGISTERED OWNER DATE

REG 1000 IB (NEW 1/2020) DMVWeb