Form Mv 371 – Fill Out and Use This PDF

MV-371 (6-16)

APPLICATION FOR A RETIRED PERSON’S $10.00 PROCESSING FEE ON A VEHICLE REGISTRATION

ELIGIBILITY INFORMATION ON REVERSE

A.

APPLICANT’S LAST NAME

FIRST NAME

MIDDLE NAME

PA DL/PHOTO ID#

DATE OF BIRTH

STREET ADDRESS

CITY

STATE

ZIP

B.

CO-APPLICANT’S LAST NAME

FIRST NAME

MIDDLE NAME

PA DL/PHOTO ID#

DATE OF BIRTH

C.

TITLE NUMBER

VEHICLE IDENTIFICATION NO

MAKE OF VEHICLE

REGISTRATION PLATE NO

INCOME INFORMATION

Total Gross Income During

the Past Calendar Year

D.

. . . . . .1. SOCIAL SECURITY, SSI PAYMENTS, RETIREMENT BENEFITS

. . . . . . .

. . . . . . . . . . . . . . .

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2. PENSIONS AND ANNUITIES

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. . . . . . .

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. . . . . .

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3. INTEREST DIVIDENDS AND CAPITAL GAINS

. . . . . . .

. . . . . . . . . . . . . . .

. . . . . .

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4. OTHER INCOME

.

Total. . . . Income.

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Did you pay the $10 Processing Fee for your last renewal?

Yes

No

(Add 1 thru 4)

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 D.

E.

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}).

Applicant Signature