Form Mv-140 - Request For Registration - Pennsylvania Department Of Transportation

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MV-140 (7-17)

REQUEST FOR REGISTRATION

For Department Use Only

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

initial Registration (request for plate)

Registration Renewal

a VEHiclE DEScRipTioN and oWNER NamE(S)

Expiration Date

Title Number

Vehicle Identification Number

Registration Plate Number

Make of Vehicle

Body Type

No. of Axles - (Complete only

Reg. Gross Wt. (if applicable)

Reg. Comb. Wt. (if applicable)

if truck or truck tractor.)

Date of Birth

Last Name (or Full Business Name)

First Name

Middle Name

PA DL/Photo ID#

or Bus. ID#

Date of Birth

Co-Owner Last Name

First Name

Middle Name

PA DL/Photo ID#

b cHaNgE oF aDDRESS -

H FEES - See Instructions on reverse.

Complete ONLY when reporting a change of address. LIST NEW ADDRESS.

Street Address

1. REgiSTRaTioN oR pRocESSiNg

FEE

2. FEE ExEmpT NumbER aS aSSigNED

City

State

Zip Code

by pENNDoT

c iNSuRaNcE iNFoRmaTioN

3. couNTy FEE: $5.00 (iF applicablE)

Insurance Company Name

NAIC No.

4. VETERaNS TRuST FuND (VTF)

DoNaTioN: $3.00

Policy Number

Policy Effective

Policy Expiration

5. oRgaN DoNoR TRuST FuND (oDTF)

Date

DoNaTioN: $1.00

D aDDiTioNal iNFoRmaTioN

6. No. oF DuplicaTE REg. caRDS

REQuESTED @ $2 pER caRD: ______

Odometer reading

___ ___ ___ , ___ ___ ___

(Exclude tenths)

7. ToTal:

E lESSoR iNFoRmaTioN

If the above vehicle is leased, please list the Lessor’s name in the space below. NoTE: If Form MV-1L has never been filed with PennDOT, the

leasing company (Lessor) must complete Form MV-1L and return the completed form along with this application.

Lessor Name

F applicaTioN FoR RETiRED STaTuS - Complete only if you qualify for this designation. See instruction #7 on reverse.

Eligible Applicant's Name

Eligible Applicant’s Actual Income During the Past Calendar Year

Eligible Applicant's Date of Birth

I certify under penalty of law that ALL information contained herein is TRUE and CORRECT and that I am retired and receiving Social Security and/or

other pension and income as listed in this section. My total gross income for the previous year did not exceed $19,200 and unless I am physically or

mentally incapable of driving, I am the principal driver of this vehicle. I further certify that my signature authorizes the PA Department of Transportation to

verify my/our income and that my occupation is “retired” through Internal Revenue Service income tax filings and that I understand that any

misstatement of fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year (18 Pa.C.S. Section

4904[b]).

Applicant’s Signature - NoTE: Retired person must be vehicle owner or lessee

g pENNSylVaNia VETERaNS TRuST FuND (VTF) aND/oR oRgaN DoNoR TRuST FuND (oDTF) DoNaTioN

I wish to contribute

$3 to the VTF and/or

$1 to the ODTF. (If either box is checked, please indicate the fee in Section H and include the

additional payment with your registration fee.)

i applicaNT SigNaTuRE(S)

I/We hereby make application for registration and certify under penalty of law that ALL information contained herein is TRUE and CORRECT and that

I/we understand that any misstatement of fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year

(18 Pa.C.S. Section 4904[b]).

By checking this block, I/we certify that this vehicle is a motor carrier vehicle and that it has a currently valid safety inspection. By not checking

this block, I/we certify that this vehicle is not a motor carrier vehicle.

(

)

* Owner/Lessor Signature

* Co-Owner Signature

Telephone Number

* Lessee can sign when Form MV-1L has been submitted by the lessor designating the lessee as registrant.