PennDOT Form MV-145V - PennDOT Driver and Vehicle Services

MV-145V (8-08)Commonwealth of PennsylvaniaDepartment of TransportationBureau of Motor Vehicles1101 South Front StreetHarrisburg, PA 17104-2516APPLICATION FOR DISABLEDVETERAN, SEVERELY DISABLEDVETERAN REGISTRATION PLATE ORSEVERELY DISABLED VETERANMOTORCYCLE PLATE DECALFOR DEPARTMENT USE ONLYCHECK ( ) APPROPRIATE BLOCKS BELOW and complete Sections A, B, and C. - See reverse side for eligibilityrequirements.Disabled Veteran Plate (NOTE: No Special Parking Privileges). FEE: $7.50.Severely Disabled Veteran Plate. FEE: $7.50.Severely Disabled Veteran Motorcycle Plate Decal. NO FEE REQUIRED.AVEHICLE OWNER INFORMATION (List all information as shown on current registration card)Title NumberLast NameVehicle Identification NumberCurrent Tag No.Telephone Number( )First NameMiddle Name PA DL/Photo ID#Date of BirthCo-Owner Last Name First Name Middle NamePA DL/Photo ID#Date of BirthStreet AddressCity State Zip CodeBCERTIFICATION FROM VETERANS ADMINISTRATION REGIONAL OFFICE ADMINISTRATOR OR HIS/HERDESIGNATED REPRESENTATIVE (Philadelphia or Pittsburgh) OR SERVICE UNIT IN WHICH THE VETERANSERVED.This is to certify that veteran, _______________________________, listed above with VA number _____________________________ has serviceName of Veteranconnected disabilities rated at ________% or has the following service connected disability listed on the reverse side of this application under “EligibilityRequirements”: ____________________. NOTE: If reason code #4 is listed, please indicate the type of device used: __________________________.List Reason Code # HereAuthorized Signature:Title of Authorized Signer:CNOTARIZATION AND APPLICANT SIGNATURE - Applicant listed in Section A must sign below.STASUBSCRIBED AND SWORNTO BEFORE ME MO. DAY YEARSIGNATURE OF PERSON ADMINISTERING OATHI state that I have read and signed this application after its completion, andI swear or affirm that the statements made herein are true and correct, andthat any statement made on or pursuant to this application is subject to thepenalties of 18 PA C.S. Section 4903 9(a)(2) (relating to false swearing),which shall include punishment of a fine not exceeding $5,000, or to a termof imprisonment of not more than two years, or both.MPDO NOT NOTARIZE UNLESS SIGNED INPRESENCE OF NOTARYApplicant SignatureMessenger No.( )Telephone NumberTHIS APPLICATION MAY BE DUPLICATED

ELIGIBILITY REQUIREMENTS AND GENERAL INFORMATIONPlate Type Eligibility Requirements Qualifying Vehicles BenefitsSeverelyDisabled VeteranPlate, SeverelyDisabled VeteranMotorcycle PlateDecal“Reason Codes”Applicant:(1) is blind.(2) does not have full use of an arm or both arms.(3) cannot walk 200 feet without stopping to rest.(4) cannot walk without the use of, or assistancefrom, a brace, cane, crutch, another person,prosthetic device, wheelchair or other assistivedevice.(5) is restricted by lung disease to such an extentthat the person’s forced (respiratory) expiratoryvolume for one second, when measured byspirometry, is less than one liter or the arterialoxygen tension is less than 60 MM/HG on roomair at rest.(6) uses portable oxygen.(7) has a cardiac condition to the extent that theperson’s functional limitations are classified inseverity as Class III or Class IV according to thestandards set by the American HeartAssociation.(8) is severely limited in his or her ability to walk dueto an arthritic, neurological or orthopediccondition.NOTE: In order to qualify for the free yearlyregistration, the applicant must have a 100%service- connected disability certified by the U.S.Veteran’s Administration or service unit in which theveteran served.(1) A passenger vehicle or truck with aregistered gross weight of not more than10,000 lbs. The vehicle must be used bya person with disability or operatedexclusively for the use and benefit of theperson with a disability.NOTE: Severely Disabled VeteranMotorcycle Plate Decal is for amotorcycle only.(1) Parking permitted in spacesdesigned for disabled personsand for 60 minutes in excess oflegal parking period exceptwhere local ordinances orpolice regulations provide forthe accommodation of heavytraffic during morning, afternoonor evening hours.(2) Upon request of a severelydisabled veteran, localauthorities may erect on thehighway as close as possibleto the person’s residence asign(s) indicating that the placeis reserved for the person withdisability, that no one else maypark there unless a personwith disability, severelydisabled veteran plate ormotorcycle plate decal isdisplayed and that anyunauthorized person parkingthere will be subject to a fine.DisabledVeteranPlate1) Any service-connected disability certified by U.S.Veteran’s Administration, or the service unit of thearmed forces in which the veteran served; or,2) same disabilities as listed for Severely DisabledVeteranSame as above.No special benefits.Individuals should list their PA Driver’s License (PA DL) or Photo ID# in the space provided.This application may only be used by a vehicle owner or co-owner that qualifies for the type of plate or decal indicated on the frontof this application.Only one plate or motorcycle decal per qualified person. NOTE: The decal may only be used on a currently registered motorcycleregistration plate.Disabled Veteran and Severely Disabled Veteran plates may not be personalized.Should you desire to renew your registration in conjunction with this application, you must complete Form MV-140 or your registrationrenewal application and return it with this application along with your annual registration fee and the $7.50 replacement registrationplate fee (if applicable).Send completed application to:PA Department of TransportationBureau of Motor Vehicles1101 S. Front StreetHarrisburg, PA 17104-2516Visit us at www.dmv.state.pa.us