Statement of Compliance
| Make |
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| Model |
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| Model code(s) |
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| Year of manufacture |
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| VIN/chassis number |
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| Component/system |
Standard(s) met (eg, UN/ECE Regulation No. 16 for seat belts) |
| Door retention systems |
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| Interior impact |
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| Steering systems |
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| Seats and seat anchorages |
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| Frontal impact |
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| External projections |
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| Head restraints |
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| Seatbelts |
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| Seatbelt anchorages |
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| Glazing |
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| Rear-view mirrors |
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Brakes |
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| Lighting equipment installation |
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| Lighting components |
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- Rear registration plate illumination lamps
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- Rearward-facing retroreflectors
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| Tyres |
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| In-built child restraint |
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| Side impact |
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| Emissions |
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Fuel consumption information
| Fuel consumption information must be consistent with the test cycle cited in the vehicle’s certified emissions standard; and must be provided in kilometres per litre, litres per 100 kilometres, miles per US liquid gallon or miles per Imperial gallon. |
| Urban fuel consumption |
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| Extra-urban fuel consumption |
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| Combined fuel consumption |
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| If the vehicle’s fuel consumption information is consistent with the Japanese 10.15 mode, the Japanese JC08 mode or ADR 81/01 Fuel Consumption Labelling for Light Vehicles, information may be provided for the combined cycle only. |
| Name and title |
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| Company |
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| Address |
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- I confirm that the components and systems listed above comply with UN/ECE Regulations, EEC/EC/EU Directives, ADRs, Japanese domestic standards,
or other approved standards for which type approvals are issued by the controlling jurisdictions or certification bodies at the time of manufacture.
- I also confirm that where test certificates necessary to claim compliance with the above standards are required by the controlling standards
authority, these are in existence for the vehicle(s), components and systems identified above and explicitly cover the production facility/facilities
where the vehicle(s), components and systems were manufactured.
- I also confirm that, for any components and systems complying with FMVSSs:
- test results are in existence demonstrating compliance of the components and systems with FMVSSs; and
- arrangements are in place to ensure conformity of production to cover all stages of manufacture of the vehicle(s), components and systems; and
- the components and systems are designed and manufactured for use in the USA.
