Form Mv 653V – Fill Out and Use This PDF

ATTENTION:This form is to be used only by a volunteer fire company or volunteer ambulance company to certify eligibility for Official Plates for the vehicle types described in the check boxes below. The vehicle must be registered in the name of the volunteer organization. THIS FORM CANNOT BE USED TO REGISTER AMBULANCES. Proof of vehicle insurance is required. You mustpresentavalidinsurancecardwiththisform.

VOLUNTEERFIREORVOLUNTEERAMBULANCEORGANIZATIONINFORMATION

Name of Volunteer Organization

Address

Head of Organization	Title
Business Phone	Business E-MailAddress (Optional)

DESCRIPTIONOFVEHICLE(S)(NOAMBULANCESSHOULDBELISTEDINTHISSECTION):

Checkthisboxifyouarecertifyingmultiplevehicles,andattachaseparatesheetlistingtherequestedinformationforallvehicles.

PLEASECHECKONLYONEBOXBELOW:

Thisvolunteerfirecompanyisregisteringafirevehicle,asdefinedin§115-aoftheVehicleandTrafficLaw,whichisowned orcontrolledbyafirecompany,asdefinedin§3oftheVolunteerFirefighters’BenefitLaw.

This volunteerambulancecompanyisregisteringanEmergencyAmbulanceServiceVehicle(EASV),asdefinedin§115-c oftheVehicle&TrafficLaw,whichisownedorcontrolledbyanambulancecompany,asdefinedin§3oftheVolunteer AmbulanceWorkers’BenefitLaw.

CERTIFICATION

I certify that the above-described vehicle(s) is (are) owned or controlled by the volunteer organization to which this application for registration applies, and that the information contained herein is true and accurate. I do so in my capacity as an officer who hasbeengrantedtheauthoritytoactonbehalfoftheabove-namedorganization.

I understand and agree that if, in the future, the above-described vehicle or my organization no longer meets the qualifications listed (cited in the check boxes above), it is the above-mentioned organization’s responsibility to surrender the registrationitems totheNYSDMV.Failuretosurrendertheregistrationitemsmayresultinthesuspensionoftheregistration.

I understand that knowingly making a false statement on an application submitted to the Commissioner of Motor Vehicles is a misdemeanor under Vehicle and Traffic Law, a misdemeanor or felony under New York State Penal Law, and may result in criminal prosecution in addition to revocation or suspension of the registration pursuant to regulations promulgated by the CommissionerofMotorVehicles.

Signature ➧__________________________________________________________ Date: __________________________

(Sign Your Name in Full)

Print Your Name: ______________________________________________ Title: ____________________________________

Address: ______________________________________________________________________________________________

City: _______________________________________________________________ Zip Code: __________________________

	ONLY	Authorization Code ______________________	FS Insurance Card Presented
	USE	Code from List	Insurance Company Code_________________
		Code from IOCU
			Insurance Effective Date __________________
	OFFICE
		DMV SupervisorApproval: _________________________________________________ Date: ___________________

(Signature)