Pa Mv141 Form – Fill Out and Use This PDF

MV-141 (4-18)

SURRENDER OF A REGISTRATION PLATE

Bureau of Motor Vehicles • 1101 S. Front Street • Harrisburg, PA 17104

www.dmv.pa.gov

For Department Use Only

Registration Plate Must be Attached

A

Applicant and Vehicle Information

NOTE TO VEHICLE OWNER: You must retain a copy of this receipt in order to obtain a replacement registration plate from an authorized agent.

Name of Registrant

Registration Plate Number

Title Number

B

The above registration plate is being returned to PennDOT for the following

reason(s):

1.q Replacement of Registration Plate

5. qMoved Out-of-State

9.

qTermination or Lapse of Insurance

2.q Vehicle Sold (no plate needed)

6. qInsurance Stop

10. qRegistration Privileges Suspended

3. q Voluntary Surrender

7. qVehicle Deal Cancelled

11. qOther:____________________________

4. q Personalized Registration Plate - Issued _____ 8. qExchange Registration Plate Issued

C

Decentralized Service or Full Agent Information (If applicable)

The registration plate listed above was surrendered on _______________ to the authorized agent below:

Decentralized Service or Full Agent Name

Date

City

State

Zip Code

Street Address

I certify that I have verified that the number listed on the registration plate matches the registration plate number listed above and hereby certify

under penalty of law that

ALL information contained herein is TRUE and CORRECT 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]).

______________________________________________________

______________________________________________________

_________________________

Printed Name of Authorized Agent

Authorized Agent Signature

Date

D

Law Enforcement/PennDOT Locations

The registration plate listed above was surrendered on _______________ to the authorized agent below:

Law Enforcement/PennDOT Location Name

Date

City

State

Zip Code

Street Address

I certify that I have verified that the number listed on the registration plate matches the registration plate number listed above and hereby certify

under penalty of law that

ALL information contained herein is TRUE and CORRECT 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]).

______________________________________________________

______________________________________________________

_________________________

Printed Name of Authorized Person

Authorized Person Signature

Date

E

Registration Plate Owners

I/We are surrendering the above listed registration plate to the Department on _______________.

Registration Plate Owner Name

Date

City

State

Zip Code

Street Address

I/We certify that I/we have verified that the number listed on the registration plate matches the registration plate number listed above and hereby

certify under penalty of law

that ALL information contained herein is TRUE and CORRECT and that I/we 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]).

_____________________________________________________

_______________________________________________

________________________________

Printed Name of Registration Plate Owner

Owner Signature

Date

_____________________________________________________

_______________________________________________

________________________________

Printed Name of Registration Plate Co-Owner

Co-Owner Signature

Date

NOTE TO VEHICLE OWNER: You must retain a copy of this receipt in order to obtain a replacement registration plate from an authorized agent.

FOR DEPARTMENT USE ONLY

Agent/Messenger No.

Date Received

Month

Day

Year