Fillable Printable Form MV-412 - Application for Military and Veteran Custom Plates - New York

Form MV-412 - Application for Military and Veteran Custom Plates - New York

* Air Force Reserve (Letter from CO certifying Reserve status — Initial Fee: $38.75; cannot be personalized; not for use with a

commercial registration; No Annual Fee)

* Air National Guard (Letter from CO certifying eligibility — Initial Fee: $38.75; cannot be personalized; not for use with a

commercial registration; No Annual Fee)

* Airborne (Copy of current Airborne Association Membership Card or DD-214 or Current ID Card from Army Airborne —

Initial Fee: $38.75/Personalized Fee: $70.00; Annual Fee: Personalized plates only - $31.25)

American Legion (Copy of current membership card — Initial Fee: $38.75/Personalized Fee: $70.00; Annual Fee: Personalized

plates only - $31.25)

* Army National Guard (Letter from CO certifying eligibility — Initial Fee: $38.75; cannot be personalized; not for use with a

commercial registration; No Annual Fee)

* Army Reserve (Letter from CO certifying Reserve status — Initial Fee: $38.75; cannot be personalized; not for use with a

commercial registration; No Annual Fee)

Coast Guard Auxiliary (Copy of current Auxiliary Card - both sides — Initial Fee: $47.50/Personalized Fee:$78.75;

Annual Fee: Standard plates - $18.75/Personalized plates - $50.00)

* Coast Guard Reserve (Letter from CO certifying Reserve status or copy of active Coast Guard Reserve ID— Initial Fee: $38.75;

cannot be personalized; not for use with a commercial registration; No Annual Fee)

Combat Infantrymen (Copy of DD-214 and certification from NYS Commander — Initial Fee: $38.75/Personalized

Fee: $70.00; Annual Fee: Personalized plates only - $31.25)

Congressional Medal of Honor (Proof of Award - No fees; cannot be personalized; not for use with a commercial registration)

Disabled American Veterans (DAV) (Contact organization for approval — Initial Fee: $38.75/Personalized Fee: $70.00 —

motorcycle plates — Initial Fee: $26.25/Personalized Fee: $45.00; Annual Fee: Personalized plates only - Passenger or Commercial -

$31.25/motorcycle - $18.75)

Disabled Veteran (This plate displays the International Symbol of Access ). Copy of DD-214 proving war-time veteran; and

for applicants who do not already have a plate with the International Symbol of Access, MV-664.1, “Application for License Plates

or Parking Permits for People with Severe Disabilities”, OR a letter from a Medical Doctor, Doctor of Osteopathy, Nurse Practitioner,

Physician Assistant or Doctor of Podiatric Medicine verifying a permanent disability that affects mobility — Initial Fee: $28.75;

cannot be personalized; not for use with a commercial registration; No Annual Fee)

* Eighth Air Force (Copy of current membership card — Initial Fee: $43.75/Personalized Fee: $75.00; not for use with a

commercial registration; Annual Fee: Standard plates - $15.00/Personalized plates only - $46.25)

Former Prisoner of War (Proof of POW status: Copy of DD-214 or letter from VA — No fees; cannot be personalized; not for use

with a commercial registration)

Forty and Eight (40 & 8) (Copy of current membership card — Initial Fee: $60.00/Personalized Fee: $91.25;

Annual Fee: Standard plates - $31.25/Personalized plates - $62.50)

MV-412 (8/15)

HOW TO APPLY FOR MILITARY OR VETERAN CUSTOM PLATES

Select the type of plate you are requesting from the list below, then write it in the appropriate box on page 3 of the application form.

You must

provide the appropriate proof(s) when you mail your application to the address shown on the application form. Required proof(s)

and initial cost information are in parentheses after each plate.

NOTE: Plates marked below with an asterisk (*) can be issued: (1) in the name of the veteran or military member; or (2) in the name of the

spouse of the veteran or military member. Plates will

NOT be issued to both unless both spouses are eligible for the plates.

If you need the International Symbol of Access on your new plates and you do not have it on your current plates, you must also submit a

completed form MV-664.1.

PAGE 1 OF 3

APPLICATION FOR MILITARY AND VETERAN CUSTOM PLATES

www.dmv.ny.gov

NOTE: Not all military plates can be personalized. Only those plates that refer to a “personalized fee” can be personalized.

Don’t forget, write down on page 3 which military or Veteran plate you want to order!

For a complete listing of all custom plates of if you have any questions or need additional information,

call us at (518) 402-4838 or visit our website www.dmv.ny.gov/cplates.htm

MV-412 (8/15)

PAGE 2 OF 3

Gold Star Mother (Official document stating that child lost life while serving in the military — Initial Fee: $28.75; cannot

be personalized; not for use with a commercial registration; No Annual Fee)

Jewish War Veterans of America (Letter from Association — Initial Fee: $38.75; cannot be personalized; not for use with

a commercial registration; No Annual Fee)

Korean War Veterans (Copy of DD-214 or letter from VA verifying service dates between 6/27/50 - 1/31/55 —

Initial Fee: $38.75/Personalized Fee: $70.00; Annual Fee: Personalized plates only - $31.25)

Marine Corps League (Letter from MCL Paymaster — Initial Fee: $38.75/Personalized Fee: $70.00; Annual Fee: Personalized

plates only - $31.25)

* Marine Corps Reserve (Letter from CO certifying Reserve status or copy of active Marine Corps Reserve ID — Initial Fee:

$38.75; cannot be personalized; not for use with a commercial registration; No Annual Fee)

* Naval Militia (Letter from CO certifying eligibility — Initial Fee: $38.75; cannot be personalized; not for use with a

commercial registration; No Annual Fee)

* Navy Reserve (Letter from CO certifying Reserve status or copy of active Navy Reserve ID — Initial Fee: $38.75; cannot be

personalized; not for use with a commercial registration; No Annual Fee)

* Pearl Harbor Survivor (Copy of DD-214 and official statement verifying service at Pearl Harbor on 12/7/41 —

Initial Fee: $38.75; cannot be personalized; not for use with a commercial registration; No Annual Fee)

* Persian Gulf Veteran (Copy of DD-214 verifying service in the Persian Gulf between 8/2/90 and 4/6/91 — Initial Fee: $38.75/

Personalized Fee: $70.00; Annual Fee: Personalized plates only - $31.25)

Purple Heart Recipient (Proof of award: Copy of DD-214 or letter from VA — Initial Fee: $28.75/Personalized Fee: $60.00 —

motorcycle plates-Initial Fee: $16.25/Personalized Fee: $35.00; Annual Fee: Personalized plates only - Passenger or Commercial -

$31.25/motorcycle - $18.75)

Saratoga National Cemetery Honor Guard Association (Copy of current membership card and application authorized by the

Association. Initial Fee: $43.75/Personalized Fee: $75.00; Annual Fee: Standard plates - $15.00/Personalized plates - $46.25)

* State Guard (Letter from CO certifying eligibility — Initial Fee: $38.75; cannot be personalized; not for use with a

commercial registration; No Annual Fee)

U.S. Naval Armed Guard (Copy of DD-214 or letter from a U.S. Naval Armed Guard authority verifying that the applicant was

honorably discharged from the US. Naval Armed Guard — Initial Fee: $38.75/Personalized Fee: $70.00; Annual Fee: Personalized

plates only - $31.25)

U.S. Submarine Veterans (Contact U.S. Submarine Veteran’s Group for approval — Initial Fee: $38.75/ Personalized Fee:

$70.00; Annual Fee: Personalized plates only - $31.25)

U.S. Veteran (Copy of DD-214 or proof of service — Initial Fee: $38.75/Personalized Fee: $70.00 — motorcycle plates- Initial

Fee: $26.25/Personalized Fee: $45.00; Annual Fee: Personalized plates only - Passenger or Commercial - $31.25/motorcycle - $18.75)

Veterans of Foreign Wars (Copy of current Veterans of Foreign Wars Membership Card — Initial Fee: $38.75/Personalized

Fee: $70.00; Annual Fee: Personalized plates only - $31.25)

Vietnam Veteran (Copy of DD-214 verifying service dates between 12/22/61 - 5/7/75 — Initial Fee: $38.75/Personalized Fee: $70.00)-

motorcycle plates- Initial Fee: $26.25/Personalized Fee: $45.00: Annual Fee: Personalized plates only - Passenger or Commercial -

$31.25/motorcycle - $18.75)

Vietnam Veterans of America (Letter from organization and copy of DD-214 verifying service dates between 12/22/61 - 5/7/75 —

Initial Fee: $38.75; Personalized Fee: $70.00; Annual Fee: Personalized plates only - $31.25)

War on Terror Veteran (Copy of DD-214 verifying service in the Persian Gulf or Afghanistan on or after 9/11/2001 —

Initial Fee: $38.75/Personalized Fee: $70.00; Annual Fee: Personalized plates only - $31.25)

World War II Veterans (Copy of DD-214 verifying service dates between 1941 and 1945 — Initial Fee: $38.75/

Personalized Fee: $70.00; Annual Fee: Personalized plates only - $31.25)

Personalized Passenger or Commercial Plates

The military emblem or picture will be shown on the left side of the plate. A maximum of six

spaces is allowed for the letter/number combination.

If the International Symbol of Access is required, four or five

spaces are allowed. Please call or check our website for exact space

allowances. You may provide up to three letter/number combination choices. To show a space, put a period (.) on the line in the choice where you

want the space. DMV reserves the right to reject, recall or cancel any plate that is deemed objectionable. This includes plates that have

already been issued.

1st ___ ___ ___ ___ ___ ___ 2nd ___ ___ ___ ___ ___ ___ 3rd ___ ___ ___ ___ ___ ___

o Passenger o Commercial o Motorcycle

IMPORTANT: Making a false statement in any registration application or in any proof of statements in connection with it, or deceiving or

substituting in connection with this application, is a misdemeanor under Section 392 of the Vehicle and Traffic Law, and may also result in

the revocation or suspension of the registration and/or the applicant’s license pursuant to regulations established by the Commissioner. The

act of renewing these plates shall constitute your certification that you remain eligible to continue holding these plates.

I would like to apply for:

o Standard plates (number assigned by DMV) o Personalized plates o ISA Requested (You must qualify)

Personalized Motorcycle Plates (US Veteran, Purple Heart, Vietnam Veteran and DAV only) (see DAV eligibility details

on page 1)

The military emblem or picture will be shown on the left side of the plate. A maximum of four spaces is allowed for the letter/number

combination. If the International Symbol of Access is required, only three spaces are allowed. You may provide up to three letter/

number combination choices. To show a space, put a period (.) on the line in the choice where you want the space. DMV reserves the right

to reject, recall or cancel any plate that is deemed objectionable. This includes plates that have already been issued.

1st ___ ___ ___ ___ 2nd ___ ___ ___ ___ 3rd ___ ___ ___ ___

MV-412 (8/15)

Payment Method:

Check

MasterCard

Discover

Money Order

Visa

American Express

Name (as it appears on credit card)_______________________________________________________________________

Credit Card Number ____________________________________________ Expiration Date__________________________

Authorized Signature

_________________________________________________________________________________

Please do not send cash! Make the check or money order payable to “Commissioner of Motor Vehicles”.

Please allow 4 to 6 weeks for delivery. If there is an annual fee for your plate, the fee is in addition

to the renewal fee to register your

vehicle. You will be billed for the plates every two years when you renew your registration.

Return this completed form, the required proof, and payment to:

Department of Motor Vehicles, Custom Plates Unit,

PO Box 2775, Albany, NY 12220-0775

PLEASE PRINT INFORMATION BELOW

Last Name

Address (Include Street Number and Name and/or Rural Delivery Box No.)

Apt. #

Current Plate Number

Vehicle Model Year Vehicle Make

City State Zip Code

Signature (Sign Name in Full)

Plate type:

Date

/ /

Daytime Phone (include area code)

( )

First M.I. Date of Birth (Month/Day/Year)

/ /

Amount Enclosed $__________________

PAGE 3 OF 3

Which military/veteran plate are you applying for? (Refer to the list on pages 1 and 2.) _________________________________________________

(Example: Former POW, Purple Heart, U.S. Veteran, etc.)

Did you remember to write down which military or Veteran plate you would like to order?

Are you receiving all of your Veterans’ benefits?

For free assistance, call the NYS Division of Veterans’ Affairs at 1-888-838-7697

Do your current plates have the

International Symbol of Access?

o Yes o No

If you need the International Symbol of Access on your new plates and you do not have it on your current plates,

you must also submit a completed form MV-664.1, which may be printed from the DMV web site.

APPLICATION FOR MILITARY AND VETERAN CUSTOM PLATES