Free MV2951 Gold Star License Plate Application - Wisconsin

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GOLD STAR LICENSE PLATE APPLICATION
Wisconsin Department of Transportation MV2951 6/2008 s.341.14 (6r) (f) 19m Wis. Stats. _____ I would like nonpersonalized Gold Star plates.

_____ I would like personalized Gold Star plates Note: If all personalized choices have been used: _____ I would like nonpersonalized plates _____ Call me at ___________________________ between 7 a.m. and 4:30 p.m. _____ E-mail me at _________________________

1st Choice 2nd Choice 3rd Choice
Current License Plate # Year - Make

Meaning Meaning Meaning Body Type Vehicle Identification #

Owner(s)/Lessee Name (Last, First, M.I.) - Print

Social Security # or Driver License # or (If company owned) FEIN #

Street Address

Telephone # where you may be reached 7 a.m. to 4:30 p.m.

City

State

ZIP Code

The social security number is used for identification purposes.

(Applicant Signature)

AFFIRMATION FOR GOLD STAR LICENSE PLATES

Section 341.14 (6r) (f) 19m of the Wisconsin statutes states that Gold Star plates are available for persons who have had
an immediate family member die while serving in the U.S. Armed Forces or in forces incorporated as part of the U.S. armed forces if the immediate family member meets any of the criteria specified in 10 USC 1126(a)(1) to (3) for a gold star lapel button. (Immediate family member means a spouse, grandparent, parent, sibling, child, stepchild, stepparent, or grandchild, or the spouse of a grandparent, parent, sibling, child, stepchild, stepparent, or grandchild.)
Name of Service Member who died

Relationship to Service Member

I affirm that the identified Service Member died while serving in the U.S. Armed Forces and that I qualify per the specified relationship.
(Signature) (Date)

How to Apply
1. To order nonpersonalized Gold Star (GST) plates, mark application and omit steps 2-4. 2. To order personalized GST plates, choose 1-6 characters. If you choose 6 characters, no spaces are allowed. 5. If the vehicle that you wish to register with GST plates is already titled in your name, send: * A copy of your Certificate of Registration OR the complete vehicle description on the application above; * $15.00 personalized plate fee, if applicable, plus the annual registration fee if the current plates expire within the next 3 months. 6. If the vehicle is NOT titled in your name, send: * A completed title application (MV1 or MV11) and fees, including annual registration fee; * Additional $15.00 personalized plate fee, if applicable. 7. Send this application with "Affirmation for Gold Star License Plates" completed and signed. 8. Make check or money order payable to: Registration Fee Trust. 9. Mail all required items to: Wisconsin Department of Transportation Special Plates Unit PO Box 7911 Madison, WI 53707-7911

2 H O N O R
If you choose 5 characters, you may request up to 2 spaces between any of the characters. Indicate spaces with diagonal lines.

L O V E M
3. Use capital letters or numbers. The letter O and the number zero are the same. The following are not acceptable: small letters, symbols, signs, hyphens, apostrophes, etc. Carefully distinguish between: Letters L or I and Number 1 Letter Z and Number 2 Letter S and Number 5 Letter B and Number 8 Letter G and Number 6 Letter U and Letter V 4. Provide meaning of request, i.e., what does this represent?

General Information
When you request Gold Star plates, you pay: Your regular registration fee, if your current plates expire within 3 months. An annual $15.00 personalized plate fee if you choose to personalize your plate.

Release of Nonexempt Information
The Wisconsin Department of Transportation uses the information on this form to issue Gold Star license plates. Under open records laws, the Department must make nonexempt information available upon request. Do you want your name withheld from mailing lists of 10 or more individuals? Yes. This will remove your name from marketing lists.

6

Gold Star Family

If your personalized request is not available, on the form, check which option you would like us to follow. WIDOT may refuse to issue or recall after issuance, a request that is misleading or may be offensive to good taste or decency. No refund or adjustment will be made for a change of choice or spacing after the plate has been ordered, or if the application is unclear or incorrectly completed. Plates will be mailed 4-6 weeks after you receive a new Certificate of Registration.

No.

Release of Personalized Plates

I authorize the re-issuance of my personalized license plate number specified above to applicant shown on other side. I allow the Department of Transportation to reissue my current personalized plate after it is replaced with a different plate. X
(Signature of Owner Releasing Plate)

GOLD STAR LICENSE PLATE APPLICATION
Gold Star license plates are issued to any person who has had an immediate family member die while serving in the U.S. Armed Forces or in forces incorporated as part of the U.S. armed forces if the immediate family member meets any of the criteria specified in 10 USC 1126(a)(1) to (3) for a gold star lapel button. The qualified individual must be an owner, lessee, or trust beneficiary.

Plates Required in 2 Days To legally operate your vehicle, you must display license plates within two business days of purchase. If you do not have current plates, apply to a DMV Customer Service Center or an agent authorized by DMV to obtain a temporary plate while your personalized plate order is processed. An agent may charge a $3 plate fee and / or may also charge a $5 service fee.

New Owner - please check one: Have plates in good condition in my possession Need new plates issued Note: No credit of registration fees or personalized plate fee from former owner is allowed.

If you have questions: call 608-266-3041; e-mail: [email protected] or write to the address given.

IMPORTANT NOTICE NO special parking privileges are provided with Gold Star plates.

ADA - The Wisconsin Department of Transportation complies with the Americans with Disabilities Act.

MV2951

Wisconsin Department of Transportation

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