Free TC-142, Application for Special Plates and Decals - Utah

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Utah State Tax Commission

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TC-142
Rev. 8/08

Application for Special Plates and Decals

Return application and fees to :

Motor Vehicle Enforcement Division 210 North 1950 West Salt Lake City, UT 84134 Telephone: 801-297-2600

Make check or money order payable to Utah State Tax Commission Please use a separate form for each license type. _ _ _ _ _ _ _ Company name: _____ _ _ _ _ _ _ ___________ License number: ____________ Manufacturer Dealer Transporter Dismantler

As owner, partner or corporate officer of the above company, I am applying to the Utah State Tax Commission for the following items: _ _ _ _ Dealer plates ($12.00 each ­ includes decal) ....................................................................... $ ______ _ _ _ _ _ _ _ _ _ _ _ _ _ Motorcycle plates ($12.00 each ­ includes decal) ................................................................ $ ______ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dismantler, manufacturer or transporter plates ($10.00 each).............................................. $ ______ _ _ _ _ _ _ _ _ _ _ Renewal decals for dealer plates ($10.50 each) ................................................................... $ ______ _ _ _ _ _ _ _ _ _ _ _ _ _ Renewal decals for dismantler, manufacturer or transporter plates ($8.50 each) ................. $ ______ _ _ _ _ _ _ _ _ _ Additional instructions: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________ Decal number (office use only):_ _ _ _ _ _ ___________________ _ _ _ _ _ _ Renewal decals are for plate numbers: _ _ _ _ _ _ _ __ __________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________ I, the undersigned, being duly sworn, depose, and say that I have applied for a license to engage in the business shown above; and I hereby make application for special license plates. The license plates will not be used on any vehicle other than the vehicles authorized under the provisions of the law. I further certify, under penalty of law, that all vehicles operated, displaying such special plates, will be insured as prescribed by law. Insurance company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ Address ________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ Policy number _______ _ _ _ _ _ _ _ Telephone number _____ _ _ _ _ _ _ _ Total $ ______ _ _ _ _ _ _

Complete the rest of this form after it has been printed. _______________________ _ _ _ _ _ _ _
Firm name

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Signature (must be signed by owner, partner or corporate officer or signer designated by POA on file with MVED)

_______________________ _ _ _ _ _ _ _
Printed name of signer

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Date

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