Form Rv F1310701 – Fill Out and Use This PDF

STATE OF TENNESSEE

DEPARTMENT OF REVENUE

VEHICLE SERVICES DIVISION

Government Service Vehicle Registration Application

As provided by Tenn. Code Ann. § 55-4-223, vehicles owned by

•the United States government, the State of Tennessee or any of its political subdivisions,

•private or volunteer fire departments,

•senior citizen service centers that meet the standards set by the Commission on Aging for eligibility to receive state funds,

•human resource agencies and development districts,

•community actions agencies

are eligible to be registered w ith government service vehicle registration plates.

Vehicles contracted or leased by an applicant, but not owned by the applicant, are not eligible to be registered with government service vehicle registration plates.

Vehicles registered with government service plates must be operated exclusively for essential government purposes or exclusively for fire protection purposes. Qualified senior citizen service centers, human resource agencies, development districts, and community action agencies may register vans owned by the organization. These vans must be used exclusively for the activities the organization. Independent contractors operating a local transit company may also qualify for government plates under certain conditions per Tenn. Code Ann. § 55-4-223(c)1. For more information, please visit www.tn.gov/revenue.

Applicant Information

Nam e of Agency: _________________________________ Date of Application: ____________________

Qualified Purpose (check one): □ Federal Government □ State Government □ County Government

□City Government □ Volunteer Fire Department □ Senior Citizen Center □ Local Transit Service

Agency Address: ____________________________________ Telephone N umber: _________________

Nam e and Title of Person Making Application: _______________________________________________.

Vehicle Information

Make	Model	Vehicle Identification Number	License Number

If applicable, check one of the following:

□Blind Registration: Registration issued to a government agency for the purpose of concealing the identity of department heads or state officials.

□Undercover: Registration issued to a government agency in a bogus name for the purpose of concealing the identity of law enforcement typically involved in surveillance.

RV-F1310701 (Rev. 7-12)

CERTIFICATION

Under penalties of perjury, I hereby certify that the listed vehicle(s) are owned by the governmental agency or other qualified agency indicated above and that the vehicle(s) will be operated exclusively for essential government purposes as defined by Tenn. Code Ann. § 55-4-223.

________________________________________	________________________
Applicant's Signature	Date
Notary Statement:
State of Tennessee, __________________________ County

Sworn and subscribed to before me this __________ day of ___________________, 20______.

Notary Public: _______________________________

My Commission Expires: ___________________________

For Revenue or County Clerk Use Only:

Application is: □ Approved □ Denied

Reason for denial: ______________________________________

Signature of Revenue Official/County Clerk: ____________________________ Date:____________

RV-F1310701 (Rev. 7-12)