Form Mv-197 - Exempt Vehicle Certification printable pdf download

EXEMPT VEHICLE CERTIFICATION

Name of Registrant (Print or Type)

Street address

City

State

Zip Code

Vehicle Identification Number

Plate number

AMBULANCE

- An ambulance is a vehicle designed, appropriately equipped, and used for the purpose of carrying and

providing emergency health care for sick/injured persons by a person or entity registered or certified as an ambulance service

by the Department of Health. An ambulance certification (MV-3A) and Ambulance Service Certificate (DOH-3414) are required

to register an ambulance in addition to this form. An ambulance is exempt from “For-Hire” insurance and/or registration fees

if no charge is made for services, or if the cost of service is incidental to the operation of a non-profit hospital.

Check the box that applies to the ambulance listed above:

You must provide a New York State Insurance Identification Card

This ambulance is exempt from “For-Hire” insurance.

(Form FS-20) to register an ambulance if “For-Hire” insurance coverage is not required.

No charge is made for services, or the cost of service is incidental to the

This ambulance is exempt from registration fees.

operation of a non-profit hospital.

The certification below must be signed: if the vehicle is registered by a firm or corporation, an officer of the corporation must sign the

certification.

CERTIFICATION

By checking the above box(es) I, ______________________________________________________, affirm under penalty of perjury

that the vehicle is an

and no charge is made for services, or the cost of service is incidental to the operation of a non-profit

ambulance

hospital. I am the owner of this vehicle, or an officer of the firm or corporation registering this vehicle.

SIGNATURE

_____________________________________________

TITLE OR POSITION _________________________

(must be an officer of the corporation)

BUS

- A bus is a motor vehicle having a seating capacity of fifteen (15) or more passengers in addition to the driver and used

for the transportation of persons. A bus is exempt from “For-Hire” insurance if no charge, direct or indirect, is made for carrying

any persons. Registration fees apply.

No charge, direct or indirect, is made for carrying any persons. The vehicle

This bus is exempt from “For Hire” insurance.

has a seating capacity of ________ and is used as follows:______________________________________________________.

You must provide a New York State Insurance Identification Card (Form FS-20) to register a bus if “For-Hire” insurance

You can obtain the required insurance coverage and identification card from any insurance company

coverage is not required.

authorized to do business in New York State.

The certification below must be signed: if the vehicle is registered by a firm or corporation, an officer of the corporation must sign the

certification.

CERTIFICATION

By checking the above box I, _____________________________________________, affirm under penalty of perjury that the vehicle

is a

and no charge direct or indirect, is made for carrying any persons. I am the owner of this vehicle, or an officer of the firm or

bus

corporation registering this vehicle.

SIGNATURE

_____________________________________________

TITLE OR POSITION _________________________

(must be an officer of the corporation)

MV-197 (5/16)

Form Mv-197 - Exempt Vehicle Certification

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