Form Mv-655 - Request For Exemption Fromuse Of Political Subdivision License Plates
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1MV-655 (10/17)
REQUEST FOR EXEMPTION FROM USE OF
POLITICAL SUBDIVISION LICENSE PLATES
gency Name: __________________________________________________________________________
A
Address: __________________________________________________________________________
__________________________________________________________________________
STANDARD SERIES LICENSE PLATES ARE BEING REQUESTED FOR THE FOLLOWING VEHICLE:
CURRENT PLATE
YEAR
MAKE
VIN
(if registered)
The vehicle listed above qualifies for standard series license plates for the reason selected below (please initial the ap-
plicable exception):
______ The vehicle is assigned to the political subdivision’s highest ranking publicly elected official.
______ The vehicle is primarily used for law enforcement or criminal investigative work.
______ The vehicle is a limited use automobile (a vehicle with a maximum performance speed of 40 mph or less).
ATTENTION:
This does not pertain to vehicles that are not issued standard size plates including ATVs, boats, motorcycles,
and snowmobiles. Vehicles not used for one of the qualifying reasons above must be registered with PSD license plates
that display the PSD name. If the primary use of the vehicle listed above changes and no longer qualifies for exemption,
the vehicle must immediately be re-registered with PSD plates.
CERTIFICATION
I certify that the above-described vehicle is registered or controlled by the PSD to which this application for registration
applies, and that the information contained herein is true and accurate. I do so in my capacity as a duly appointed head official
of the above-named PSD.
I understand that knowingly making a false statement on an application submitted to the Commissioner of Motor Vehicles
is a misdemeanor under the Vehicle and Traffic Law, a misdemeanor or felony under New York State Penal Law, and may
result in criminal prosecution in addition to revocation or suspension of the registration pursuant to regulations promulgated
by the Commissioner of Motor Vehicles.
?
Date
Signature
Title
Print Name
(
)
Business Phone Number
Business E-Mail Address
DMV
Authorization Code: _________________
USE
£
£
ONLY
Code from List
Code from IOCU
DMV Supervisor Approval
RESET/CLEAR
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