Form Mv-140 - Request For Registration

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MV-140 (11-13)
www dot state pa us
REQUEST FOR REGISTRATION
For Department Use Only
Bureau of Motor Vehicles • 1101 South Front Street • Harrisburg, PA 17104-2516
initial registration (request for plate)
registration renewal
a veHiCle desCriPtion and oWner naMe(s)
Current Expiry Date
Title Number
Vehicle Identification Number
Plate Number
Make of Vehicle
Body Type
No. of Axles - (Complete only
Reg. Gross Wt. (if applicable)
Reg. Comb. Wt. (if applicable)
if truck or truck tractor).
Date of Birth
Last Name (or Full Business Name)
First Name
Middle Name
PA DL or Photo ID #
or Bus. ID #
Date of Birth
Co-Owner Last Name
First Name
Middle Name
PA DL or Photo ID #
B CHanGe oF address - Complete ONLY when reporting a change of address. LIST NEW ADDRESS
Street Address
City
State
Zip Code
C insuranCe inForMation
Insurance Company Name
NAIC No.
Policy Number
Policy Effective Date
Policy Expiration Date
d additional inForMation
Number of duplicate cards
Fee exemption code (if applicable)
Odometer reading
_ _ _ , _ _ _
requested at $1.50 per card
(Exclude tenths)
e lessor inForMation
If the above vehicle is leased, please list the Lessor’s name in the space below. NOTE: If Form MV-1L has never been filed with PennDOT, the
leasing company (Lessor) must complete Form MV-1L and return the completed form along with this application.
Lessor Name
F aPPliCation For retired status - Complete only if you qualify for this designation. See instruction #7 on reverse.
Applicant’s Date of Birth
Actual Income During the Past Calendar Year
Co-Applicant’s Date of Birth
I certify under penalty of law that ALL information contained herein is TRUE and CORRECT and that I am retired and receiving Social Security and/or
other pension and income as listed in Section F. My total gross income for the previous year did not exceed $19,200 and unless I am physically or
mentally incapable of driving, I am the principal driver of this vehicle. I further certify that my signature authorizes the PA Department of Transportation to
verify my/our income and that my occupation is “retired” through Internal Revenue Service income tax filings and that I understand that any
misstatement of fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year (18 PA. C.S. Section
4904{b}).
7
* Applicant’s Signature - NOTE: Retired person must be vehicle owner or lessee
G Pennsylvania veterans’ trust Fund (vtF) and/or orGan donor trust Fund (odtF) donation
o
o
I wish to contribute
$3 to the VTF and/or
$1 to the ODTF. (If either box is checked, please include the additional payment with your
registration fee.)
H aPPliCant siGnature(s)
I/We hereby make application for registration and certify under penalty of law that ALL information contained herein is TRUE and CORRECT and that
I/we understand that any misstatement of fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year
(18 PA. C.S. Section 4904[b]).
o
By checking this block, I/we certify that this vehicle is a motor carrier vehicle and that it has a currently valid safety inspection. By not checking
this block, I/we certify that this vehicle is not a motor carrier vehicle.
(
)
7
7
* Owner/Lessor Signature
* Co-Owner Signature
Telephone Number
* Lessee can sign when Form MV-1L has been submitted by the lessor designating the lessee as registrant.
Messenger no.

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