Mva Form Vr 059 – Fill Out and Use This PDF

MOTOR VEHICLE ADMINISTRATION

6601 Ritchie Highway, N.E.VR-059 (02/12) Glen Burnie, Maryland 21062

Application for License Plates for Facilities

Please read instructions on back carefully before completing form

A. Facility Information

Name of Facility:			Soundex #:
Street Address:			FEIN No.:
City:	County:	State:		Zip Code:

B. Leasing Company Information (if vehicle is leased)

Name of Owner:

Street Address:

	City:	County:	State:	Zip Code:

C. Vehicle Information

Vehicle Identiication Number (VIN):			Year:		Make:	Model:		Body Style:
Class:	Lift Equipment	Present Tag Number:		Present Sticker Number:			Title Number:
	❑ (check here)

D. Certiication Statement - Owner, Oficer of Corporation, Member of LLC, or Partner in Partnership

Certiication Statement: I, the undersigned applicant for these special tags, hereby certify, under the penalties prescribed in Maryland Vehicle law, that the vehicle described above is used exclusively for the transportation of individuals with disabilities and that if the vehicle for which these plates are issued ceases to be operated for or by the above named Facility, the plates must be returned to the Motor Vehicle Administration immediately.

Signature of Vehicle Owner:			Telephone No.:	Date:
Signature of Facility Representative:			Telephone No.:	Date:
	Do not write below this line
	MVA Use Only
Tags Issued:

For more information, please call: 1-800-950-1MVA (1682) (to speak with a customer service representative),

From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov

Instructions

Application for License Plates for Facilities

Form Purpose:

This form is used by facilities with a vehicle that is used exclusively to transport individuals with disabilities.

A facility is deined as a nursing home, health care facility, adult day care facility, retirement home, or other facility that regularly provides transportation for individuals with disabilities.

Disability license plates issued to a facility must be used exclusively for the transportation of individuals with disabili- ties and if the vehicle, for which these plates are issued ceases to be operated for or by the facility, the plates must be returned to the Motor Vehicle Administration.

Fee Information:

The request for a disability plate requires the assessment of a substitute/replacement tag fee. Please submit your completed application along with the appropriate $20.00 fee. If requesting a disability plate and it is time to renew your vehicle registration, the registration renewal fee is also required. The registration fee will vary by the type and use

of the vehicle.

Form Completion Instructions:

Section A—Facility Information

Enter the information requested about the facility requesting plates.

Section B—Leasing Company Information (if vehicle is leased)

Enter the vehicle’s owner’s name (and co-owner, if any) and address. Include the business name and business telephone number.

Section C—Vehicle Information

Enter the information requested about the vehicle.

Section D—Certiication Statement - Owner, Oficer of Corporation, Member of LLC, or Partner in Partnership Review the Certiication Statement and sign where indicated.

Only vehicles titled in a company name qualify for Facility Plates.

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