Form Mv-145v - Application For Disabled Veteran, Severely Disabled Veteran Registration Plate Or Severely Disabled Veteran Motorcycle Plate Decal

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MV-145V (8-16)

APPLICATION FOR DISABLED VETERAN,

SEVERELY DISABLED VETERAN REGISTRATION

PLATE OR SEVERELY DISABLED VETERAN

For Department Use Only

MOTORCYCLE PLATE DECAL

Bureau of Motor Vehicles • 1101 S. Front Street • Harrisburg, PA 17104-2516

CHECK ( 3 ) APPROPRIATE BLOCKS BELOW - See reverse side for eligibility requirements.

Severely Disabled Veteran Plate (E4) - Complete Sections A, B, C, D (if applicable) and E. FEE: $11.

Severely Disabled Veteran Motorcycle Plate Decal - Complete Sections A, B, C and E. NO FEE REQUIRED.

Disabled Veteran Plate (12) - Complete Sections A, B, C, D (if applicable) and E. FEE: $11. (NOTE: No Special Parking Privileges.)

Two Plates (with identical plate numbers) for vehicles equipped with a Wheelchair/Personal Assistive Device Carrier. (See reverse for instructions)

For two Severely Disabled Veteran Plates (IX) - Complete Sections A, B, C, D (if applicable) and E. FEE: $11

For two Disabled Veteran Plates (IW) - Complete Sections A, B, C, D (if applicable) and E. FEE: $11 (NOTE: No Special Parking Privileges.)

VEHICLE AND APPLICANT INFORMATION (List all information as shown on current registration card.)

Title Number

Vehicle Identification Number

Current Registration Plate Number

Current Expiration Date

PA DL/Photo ID#

Date of Birth

Street Address

Owner Name

City

State

Zip Code

Co-Owner Name

Date of Birth

PA DL/Photo ID#

APPLICANT SELF-CERTIFICATION

I, the applicant, further certify that I am eligible for the product checked above based on my:

100% service-connected disability certified by the U.S. Department of Veterans Affairs or service unit in which I served as completed in Section C or

attached Letter of Promulgation or Awards Letter.

Loss of

a limb

or eye

or became partially paralyzed while serving in the Armed Forces of the United States.

None of the above.

To qualify for a free registration or a $10 processing fee in lieu of registration, the self-certification below must be completed. See additional

instructions on reverse.

I certify that I have not previously received a

free Severely Disabled Veteran registration or a

Disabled Veteran registration for a $10

processing fee and therefore am eligible to be exempted from registration fees as described in the instructions on the reverse.

CERTIFICATION OF ELIGIBILITY

FROM U.S. DEPARTMENT OF VETERANS AFFAIRS REGIONAL OFFICE ADMINISTRATOR (PHILADELPHIA OR PITTSBURGH) OR SERVICE UNIT

IN WHICH THE VETERAN SERVED OR A LEGIBLE PHOTOCOPY OF THE APPLICANT’S LETTER OF PROMULGATION OR AWARDS LETTER.

Applicant is applying for a Severely Disabled Veteran registration plate:

This is to certify that the veteran listed above with VA number ________________________, has a service connected disability rated at __________%.

If the service-connected disability rating is less than 100%, please list the veteran’s service-connected eligibility reason code _________ as listed on the

reverse side of this application under “Service-Connected Eligibility Requirements.” NOTE: If reason code #4 is listed, please indicate the type of

device used: _________________.

In lieu of the U.S. Department of Veteran Affairs Regional Office Administrator certification, I have attached a legible photocopy of my Letter of

Promulgation or Awards Letter that indicates I have a 100% service-connected disability.

Applicant is applying for a Disabled Veteran registration plate:

This is to certify that the veteran listed above with VA number _________________________, has service connected disability rated at __________%

and does not have one of the service-connected eligibility reason codes as listed on the reverse side of this application under “Service-Connected

Eligibility Requirements.”

Authorized Printed Name and Title

Authorized Signature

D OPTIONAL PERSONALIZATION REQUEST (Please see reverse side for additional instructions.)

Personalized registration plate choices may contain up to FIVE letters or numbers in combination. Pre-printed letter configurations or designated letter(s)

appear on personalized registration plates based on the type of plate requested. Please see the reverse side of this application for additional information.

Only one hyphen or space is permitted as part of the available spaces for personalization. No other special characters are available. Please print clearly.

SECOND

THIRD

FIRST

CHOICE:

NOTARIZATION AND APPLICANT SIGNATURE

SUBSCRIBED AND SWORN

I/We state that I/we have read and signed this application after its completion,

and I/we swear or affirm that the statements made herein are true and correct,

TO BEFORE ME

MO.

DAY

YEAR