Form Mv57 - Application For Gold Star Family License Plate

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STATE OF MONTANA
APPLICATION FOR GOLD STAR
FAMILY LICENSE PLATE
To see the license plate, visit
** Before completing, read Privacy Act Statement and Information on page 2. **
INSTRUCTIONS
Obtain supporting documentation (see sections 2G and 3D below)
Complete and sign this application
Mail completed application and supporting documents to: Montana Veterans Affairs Division
P.O. Box 5715
Helena MT 59604-5715
Montana Veterans Affairs will verify the application/supporting documents and send the applicant a letter showing
eligibility. The letter must be presented to the applicant's County Treasurer's Office when requesting the Gold Star Family
License Plate. Questions regarding the application process may be directed to
lehall@mt.gov
or (406) 324-3740.
1. APPLICANT RELATIONSHIP TO DECEASED SERVICEMEMBER
WIDOW
STEPFATHER
SON
DAUGHTER BY ADOPTION
WIDOWER
MOTHER THROUGH ADOPTION
DAUGHTER
BROTHER
MOTHER
FATHER THROUGH ADOPTION
STEPSON
SISTER
FATHER
FOSTER MOTHER IN LOCO PARENTIS
STEPDAUGHTER
HALF BROTHER
STEPMOTHER
FOSTER FATHER IN LOCO PARENTIS
SON BY ADOPTION
HALF SISTER
2. SERVICEMEMBER INFORMATION
A. NAME (Last, First, Middle Initial)
B. PAY GRADE OR RANK
C. SOCIAL SECURITY NUMBER
D. DATE OF DEATH (YYYYMMDD)
E. BRANCH OF SERVICE
F. GEOGRAPHICAL AREA OF SERVICE AT TIME OF DEATH
G. SUPPORTING DOCUMENTATION TO CONFIRM GOLD STAR FAMILY PLATE ELIGIBILITY
(Check the box that applies to the documentation attached to this application.)
DD Form 1300 - Report of Casualty
Death Notice
Other, please specify:
3. FAMILY MEMBER (APPLICANT) INFORMATION
A. NAME (Last, First, Middle Initial)
B. NUMBER, STREET, AND APARTMENT NUMBER (if applicable)
C. CITY, STATE, AND ZIP CODE
D. SUPPORTING DOCUMENTATION TO VERIFY RELATIONSHIP TO DECEASED SERVICEMEMBER
(Check the box that applies to the documentation attached to this application.)
Birth Certificate
Marriage Certificate
Adoption Record
Other, please specify:
SIGNATURE OF APPLICANT
DATE
Page 1 of 2
Montana county and state authorities reserve the right to reject any form that has been altered.
MV57 (4/10)
This form is available in alternate formats for people with disabilities.

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