Mv 653 Form – Fill Out and Use This PDF

New York State Department of Motor Vehicles

MV-653 (3/14)

STATEAGENCY/POLITICAL SUBDIVISION

CERTIFICATION OF ELIGIBILITY FOR OFFICIAL PLATES

ATTENTION: This form is to be used by NYS agencies and political subdivisions to certify eligibility for Official plates. A political subdivision is defined as a subdivision of New York State that has been delegated certain official functions of state or localgovernment,includingagovernmententitycreatedby,orundertheauthorityof,Statelaw.AvehicleassignedOfficialplates mustbeownedorcontrolledbyastateagencyorapoliticalsubdivisionandoperatedbyitsemployees,orspecificallydesignated agentsthereof,inthecourseoftheirofficialduties.Thevehiclemustbetitledand/orregisteredinthenameofthestateagencyor politicalsubdivision.Volunteer organizations are not political subdivisions, and must use form MV-653V.

PLEASE CHECK THEAPPROPRIATE BOX BELOW TO INDICATE YOUR OFFICIAL GOVERNMENT STATUS: Government Division, District or Other Government Entity:

StateAgency County City	Town Village School District	Fire District Other Government Entity
Name of NYSAgency, County, City, Town, Village, District or Other Government Entity
Department or Division
Address
Name of Department or Division Director	Business Phone	Business E-MailAddress (Optional)

DESCRIPTION OF VEHICLE(S):

Checkthisboxifyouarecertifyingmultiplevehicles. Providethevehicleinformationonthereversesideofthisform.

*Authorization is required by the Department of Homeland Security and Emergency Services (DHSES) for additional Emergency Management plates that exceed the threshold established by DHSES. Emergency Management plate applications must be signed by the highest ranking elected or appointed official. If you have questions or need further information call DHSES at (518) 242-5122.

CERTIFICATION

I certify that the above-described vehicle(s) is (are) owned or controlled by the state agency or political subdivision to which this application for registration applies, and that the information contained herein is true and accurate. I do so in my capacity as a duly appointed public officer or official who has been granted the authority to act on behalf of the above-named political subdivisionorstateagency.

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 ç______________________________________________________________ Date:________________________

(Sign Your Name in Full)

Print Your Name: ______________________________________________ Title: ____________________________________

Address: ______________________________________________________________________________________________

City: _______________________________________________________________ Zip Code: __________________________

Your Business		Your Business
Phone number (	)	E-MailAddress (optional): ____________________________________

Description of Vehicle(s)

MV-653 (3/14)