Sd Eform 2235 V2 - South Dakota License Plate Application

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SD EForm - 2235
Complete and use the button at the end to print for mailing.
HELP
V2
South Dakota
License Plate Application
MV-4000
Revised
South Dakota Department of Revenue
Division of Motor Vehicles
06/12
445 E. Capitol Avenue | Pierre, SD 57501-3185 | 605-773-3541
Applicant Information
(Detailed instructions on reverse)
Plate Type:
Vehicle
Motorcycle
Type of Application (Please check one)
New
Renewal
Re-assignment
Name of Applicant
Street Address
County
City, State, Zip Code
Vehicle Information
Year
Make
Model
VIN#
Title#
Types of License Plates
See the next page for conditions and restrictions pertaining to special license plates. For each set of plates, there is a $5 mailing fee. Please
place an “X” next to the applicable license plates.
Silver Star $10.00 + registration fee (initial); registration fee (annual) (copy of DD214 froms; copy of certificate awarded upon presentation of
medal; or other official documentation that substantiates eligibility
Distinguished Service Cross $10.00 + registration fee (initial); registration fee (annual) (copy of DD214 froms; copy of certificate awarded upon presentation of
medal; or other official documentation that substantiates eligibility
Navy Cross $10.00 + registration fee (initial); registration fee (annual) (copy of DD214 froms; copy of certificate awarded upon presentation of
medal; or other official documentation that substantiates eligibility
Air Force Cross $10.00 + registration fee (initial); registration fee (annual) (copy of DD214 froms; copy of certificate awarded upon presentation of
medal; or other official documentation that substantiates eligibility
Distinguished Flying Cross $10.00 + registration fee (initial); registration fee (annual) (copy of DD214 froms; copy of certificate awarded upon presentation of
medal; or other official documentation that substantiates eligibility
Bronze Star with Valor Service $10.00 + registration fee (initial); registration fee (annual) (copy of DD214 forms; copy of certificate awarded upon presentation of
medal; or other official documentation that substantiates eligibility
Bronze Star $10.00 + registration fee (initial); registration fee (annual) (copy of DD214 forms; copy of certificate awarded upon presentation of medal; or other
official documentation that substantiates eligibility
Pearl Harbor Survivor - $10.00 + registration fee (initial); $10.00 (annual)
Disabled American Veteran - $10.00 + registration fee (initial); $10.00 (annual)
Purple Heart - $10.00 + registration fee (initial); $10.00 (annual) (Copy of DD214 Form)
National Guard (for verification, submit copy of military ID card) - $10.00 + registration fee (initial); regis. fee (annual)
Prisoner of War - $10.00 + registration fee (initial); $10.00 (annual)
Gold Star (Family) - $10.00 + registration fee (initial); registration fee (annual). Include a copy of the Department of Defense Report of Casualty (DD Form 1300) or
death notice, or verification from the US Department of Veterans Affairs (VA) that the service member's death was service related.
Disclosure and Signature
By signing this statement, I give consent to the Veteran's Administration to release information to the South Dakota Department of Revenue
regarding my eligibility to qualify for the requested type of special license plates issued by the State of South Dakota.
V.A. CLAIM NUMBER: ______________________________________________________________________________________________________
APPLICANT SIGNATURE_______________________________________________________________________________________________________
DATE
PRINT FOR MAILING
CLEAR FORM

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