Dmv 17 A Form – Fill Out and Use This PDF

Original: complete Sections 1, 2, 3 (if applicable), 6. Reassign, retain, release: complete Sections 1, 4, 6. Replacement: complete Sections 1, 2, 5, 6.

Print the true full name of the license plate holder or purchaser: last name, first name and middle name. Enter the mailing address (street or P. O. box), city, state and ZIP code.

Mark what the license plates will be assigned to: Automobile, Commercial, Trailer or Motorcycle. Motorcycle license plates are available in Amateur Radio Station, Antique Motorcycle, California Firefighter, Former American Prisoner of War, Gold Star Family, or Purple Heart Recipient. Amateur Radio Station, Press Photographer, and Horseless Carriage license plates are not available for trailers. For Gold Star Family and California Firefighter Motorcycle license plates, decals are applied to a white license plate.

Enter the current license plate number and the vehicle identification number (VIN) of the vehicle the license plates are to be assigned to.

Under Documentation Required, mark Purple Heart Recipient, Antique Motorcycle, Gold Star Family, Former American Prisoner of War (POW), Amateur Radio Station, California Firefighter, Congressional Medal of Honor Recipient or Legion of Valor. Enter the station call letters for Amateur Radio Station, the type of medal or cross for Legion of Valor, and the requested 4 digits for Former American Prisoner of War (POW).

Attach Copy of Documentation. See page 3 for explanation. For California Firefighter Only (ELP), enter a First Choice, Second Choice and Third Choice. Indicate a half space by placing a “/” in space provided. Indicate a full space by placing an “*” in space provided. Environmental License Plate (ELP) is subject to review and approval pursuant to California Code of Regulations (CCR), Title 13 §206.02.

Under Certification Required, mark Historical Vehicle, Horseless Carriage or Press Photographer. Certify in Sections 2A or 2B.

Under Documentation AND Certification Required, mark Historical Vehicle (Commercial) or California Firefighter (Surviving Family Member). Attach Copy of Documentation. Certify in Sections 2B or 2C.

Under Documentation AND Declaration - Not for Hire, mark Pearl Harbor Survivor, Former American Prisoner of War (POW), Congressional Medal of Honor Recipient, Legion of Valor or Purple Heart Recipient. Declare in Section 3.

Section 4, Reassign, Retain, or Release: Antique Motorcycle, Historical Vehicle, Horseless Carriage License Plates cannot be reassigned or retained.

Enter the special recognition license plate number and the VIN it was removed from.

Mark Retain Interest for Future Use, Release Interest/Surrender to DMV, or Reassign. For Reassign, enter the current license plate number and the VIN it is placed on.

Section 5, Replacement: enter the special recognition license plate number. Mark One License Plate or Two License Plates for what you need, and Lost, Mutilated or Stolen for what the license plate(s) were.

Section 6, signature of the license plate holder or purchaser: you certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Sign, then enter the date and telephone number or email address.

Amateur Radio Station: issued to the motor vehicle for which registration is sought by any person holding an unexpired amateur radio station license issued by the Federal Communications Commission.

Amateur Radio Station: a copy of the license must accompany the application. The license plate's configuration will be the official amateur radio station call letters.

Amateur Radio Station: the licensee may obtain only one set of license plates (California Vehicle Code (CVC) §5005).

Antique Motorcycle: issued to any owner of a motorcycle manufactured in 1942 or prior.

Antique Motorcycle: a copy of the vehicle registration must accompany the application. For a 1943 model year motorcycle manufactured in 1942, a copy of the manufacturer's Certificate of Origin or a letter from the manufacturer indicating the manufacture date of the motorcycle must be provided (CVC §5004.5).

California Firefighter and California Firefighter (Surviving Family Member): issued to a vehicle owned, co-owned, or leased by a firefighter, retired firefighter, or volunteer firefighter, or to a surviving family member (spouse, domestic partner, or any child, including an adopted child, stepchild, or recognized natural child) of a deceased firefighter, retired firefighter, or volunteer firefighter.

California Firefighter and California Firefighter (Surviving Family Member): documentation must be submitted with the application (CVC §5101.2). Acceptable documentation is: Firefighter Department Identification (ID); International Association of Firefighters (IAFF) Membership Card; or California Professional Firefighters (CPF) Callback Association Membership Card.

Congressional Medal of Honor Recipient: issued to a vehicle owned or co-owned by a Congressional Medal of Honor recipient.

Congressional Medal of Honor Recipient: a copy of the owner's service record, a copy of the Department of Defense form 214, or a copy of the official Congressional letter which was given to the recipient when the award was bestowed must accompany the application (CVC §5101.6).

Former American Prisoner of War (POW): issued to a vehicle owned or co-owned by a former American prisoner of war as defined in CVC §324.5.

Former American Prisoner of War (POW): documentation submitted must be a letter of verification from the National Personnel Records Center or discharge papers declaring the bearer to be a former American POW (CVC §5101.5).

Legion of Valor: issued to a vehicle owned or co-owned by an Army, Navy, or Air Force Medal of Honor recipient, or an Army Distinguished Service Cross, Navy Cross, or Air Force Cross recipient.

Legion of Valor: a copy of the owner's service record or Department of Defense Form 214 must accompany the application (CVC §5101.4).

Purple Heart Recipient: issued to a vehicle owned or co-owned by a Purple Heart recipient.

Purple Heart Recipient: a copy of Executive Order awarding the Purple Heart, owner's service record, or Department of Defense form 214 reflecting the owner's Purple Heart Award is required with the application (CVC §5101.8).

You may mail this application with payment (check or money order, please do not send cash) to: DMV SPU, Mail Station D238, P.O. Box 932345, Sacramento, CA 94232-3450.