Pa Mv145 Form – Fill Out and Use This PDF

A

Vehicle Information

Title Number

Vehicle Identification Number

Current Tag No.

NOTE: In conjunction with replacement of your plate, you will receive one registration card. If additional registration cards are desired, the fee is $1.50 for each card.

Number of Duplicate Registration Cards Requested @ $1.50 each ________

B

ApplicantInformation - (List all information as shown on current registration card)

Last Name (or Full Business Name)

First Name

Middle Name

PA DL/Photo ID# or

Date of Birth

Bus. ID#

Co-Owner Last Name

First Name

Middle Name

PA DL/Photo ID#

Date of Birth

Street Address

City

State

Zip Code

NOTE: If you are the parent or the adult charged by law with the natural parent’s rights, duties and responsibilities acting on behalf of a minor child

(under 18) in place of the child’s natural parents (person in loco-parentis), you must complete the information below.

Name of Parent or Person in Loco Parentis

Relationship to Applicant

Age of Applicant Listed

in Section C

Street Address

City

State

Zip Code

C

Certification FromAHealth Care Provider Licensed or Certified in PAorAContiguous State (NewYork, New Jersey, Delaware, Maryland, West

Virginia or Ohio). THIS SECTION MUST BE COMPLETED IN FULL. - WARNING:Altering or forging a document issued by the Department, such

as a Person with Disability, Hearing Impaired Registration Plate or Motorcycle Plate Decal, or possessing, using or displaying such a

document, knowing it to have been altered, forged or counterfeited, is a misdemeanor of the first degree pursuant to the Vehicle Code, 75

PA.C.S. Section 7122, punishable by a fine of not more than $10,000 or imprisonment of not more than five years, or both.

This is to certify that _________________________________________ is under my care and (check the appropriate block):

Name of Person with Disability

qhas a hearing impairment or,qhas the following condition listed on the reverse side of this application under “Eligibility Requirements”: ____________

List Reason Code # Here

NOTE: Only those conditions listed on the reverse side of this application qualify an applicant for a person with a disability plate.

NOTE: If reason code #4 is listed above, please indicate the type of device used: _________________________________________________

(Type of Device)

Health Care Provider’s Name

Health Care Provider’s Signature

Medical License No.

Office Street Address

City

State

Zip Code

Telephone Number

(

)

D

Certification by Police Officer - Police officer may only certify that the applicant does not have full use of a leg or both legs, or is blind.

NOTE: If Section C above is completed, please skip this Section and go on to Section E.

This is to certify that ____________________________has the condition checked below and is entitled to the use and privileges of the registration plate

requested:

qblind, OR does not have full use of a leg or both legs as evident by the use of a

qwheelchair

qwalker

qcrutches

qcane/quad cane

q other prescribed device

(state device)

Officer’s Name

Officer’s Signature

Badge Number

Department/Station

City

State

Zip Code

Telephone Number

(

)

E

Notarization And Applicant Signature - Applicant, natural parent or other authorized person listed in Section B must sign below.

SUBSCRIBED AND SWORN

I state that I have read and signed this application after its completion, and I swear or

affirm that the statements made herein are true and correct, and that any statement

TO BEFORE ME:

MONTH

DAY

YEAR

made on or pursuant to this application is subject to the penalties of 18 PA C.S.

t

Section 4903(a)(2) (relating to false swearing), which shall include punishment of a

SIGNATURE OF PERSON ADMINISTERING OATH

fine not exceeding $5,000, or to a term of imprisonment of not more than two years,

or both.

S

T

(

)

A

SIGN IN PRESENCE OF NOTARY

Applicant Signature

Date

Telephone Number

M

Messenger No.

P

Plate Type

Eligibility Requirements

Qualifying Vehicles

Benefits

Hearing

Any person with a hearing impairment verified by a

No restrictions.

No special benefits.

Impaired

licensed health care provider.

Plate

Person with a Disability

Same disabilities as listed for Person with a

Motorcycle Only.

Same as above for Person

Motorcycle Plate

Disability Plate.

with a Disability Plate.