Form Mv-653 - Political Subdivision Certification Of Eligibility For Official Plates
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1
2POLITICAL SUBDIVISION CERTIFICATION
OF ELIGIBILITY FOR OFFICIAL PLATES
ATTENTION:
This form is to be used by NYS political subdivisions to certify eligibility for Official plates. A political subdivision
is defined as a subdivision of New York State that has been delegated certain official functions of state or local government,
including a government entity created by, or under the authority of, State law. A vehicle assigned Official plates must be owned or
controlled by a political subdivision and operated by its employees, or specifically designated agents thereof, in the course of their
official duties. The vehicle must be titled and/or registered in the name of the political subdivision.
Volunteer organizations are
not political subdivisions, and must use form MV-653V.
PLEASE CHECK THE APPROPRIATE BOX BELOW TO INDICATE YOUR OFFICIAL GOVERNMENT STATUS:
Government Division, District or Other Government Entity:
o
o
o
o
State of New York
City
Village
Fire District
o
o
o
o
Other Government Entity
County
Town
School District
Name of NYS Agency, County, City, Town, Village, District or Other Government Entity
Department or Division
Address
Name of Department or Division Director
Business Phone
Business E-Mail Address (Optional)
DESCRIPTION OF VEHICLE(S):
o
Check this box if you are certifying multiple vehicles, and attach a separate sheet listing the requested information for all vehicles.
o
I am transferring plate ________________________ to this vehicle.
Year
Make
Model
Vehicle ID # (VIN)
Plate Number (if currently registered)
CERTIFICATION
I certify that the above-described vehicle(s) is (are) owned or controlled by the political subdivision 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
public officer or official who has been granted the authority to act on behalf of the above-named political subdivision.
I understand that knowingly making a false statement on an application submitted to the Commissioner of Motor Vehicles is a
misdemeanor under 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.
ç
Signature
______________________________________________________________ Date: ________________________
(Sign Your Name in Full)
Print Your Name: ______________________________________________ Title: ____________________________________
Address: ______________________________________________________________________________________________
City: _______________________________________________________________ Zip Code: __________________________
Your Business
Your Business
(
)
Phone number ______________________________
E-Mail Address (optional): ____________________________________
o
o
Authorization Code ______________________
Code from List
Code from IOCU
ç
DMV Supervisor Approval:
___________________________________________
Date: _______________________
(Signature)
MV-653 (4/15)
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