Fillable Printable Form MV-653EM - Certification of Eligibility for Emergency Management Plates - New York

Form MV-653EM - Certification of Eligibility for Emergency Management Plates - New York

Government Division, District or Other Government Entity:

o State Agency o County o City o Town o Village o Authority

PLEASE CHECK THE APPROPRIATE BOX BELOW TO INDICATE YOUR OFFICIAL GOVERNMENT STATUS:

Name of NYS Agency, County, City, Town, Village, District or Authority

Department or Division

Address

Name of Department or Division Director Business Phone Business E-Mail Address (Optional)

CERTIFICATION OF ELIGIBILITY FOR

EMERGENCY MANAGEMENT PLATES

Department of Homeland Security (DHSES) authorization is required for the issuance of Emergency Management plates.

DHSES authorization is NOT required to transfer existing Emergency Management plates. This form is to be used by NYS

agencies and political subdivisions to certify eligibility for Emergency Management plates. A political subdivision is defined as a

subdivision of New York State that has been delegated certain official functions of state or local government, including a

government entity created by, or under the authority of, State law. A vehicle assigned Emergency Management plates must be

owned or controlled by a state agency or a political subdivision and operated by its employees, or specifically designated agents

thereof, in the course of their official duties. The vehicle must be registered in the name of the state agency or political subdivision.

I certify that the above-described vehicle(s) is (are) owned or controlled by the state agency or political subdivision to which

this application for registration applies, and that the information contained herein is true and accurate. I do so in my capacity as

a duly appointed public officer or official who has been granted the authority to act on behalf of the above-named political

subdivision or state agency.

I understand that knowingly making a false statement on an application submitted to the Commissioner of Motor Vehicles is a

misdemeanor under Vehicle and Traffic Law, a misdemeanor or felony under New York State Penal Law, and may result in

criminal prosecution in addition to revocation or suspension of the registration pursuant to regulations promulgated by the

Commissioner of Motor Vehicles.

Signature ç ______________________________________________________________ Date: ________________________

Print Your Name: ______________________________________________ Title: ____________________________________

Address: ______________________________________________________________________________________________

City: _______________________________________________________________ Zip Code: __________________________

MV-653EM (4/15)

(Sign Your Name in Full)

( )

DESCRIPTION OF VEHICLE(S):

o Check this box if you are certifying multiple vehicles. Provide the vehicle information on the reverse side of this form.

o I am transferring plate _____________________ to this vehicle.

CERTIFICATION

DMV Supervisor Approval: ç ___________________________________________ Date: _______________________

Authorization Code ______________________

o Code from List o Code from IOCU

(Signature)

DMV

USE ONLY

Your Business

E-Mail Address (optional): ____________________________________

Your Business

Phone number ______________________________

Year

County of Primary Use

Make Model

Plate Number (if currently registered)

Emergency Management plate applications must be signed by the highest ranking elected or appointed official. If you

have questions or need further information call DHSES at (518) 242-5122.

Signature:ç ________________________________________________________ Date: _______________________

I authorize the issuance of Emergency Management License Plates for _____ vehicles (indicate the number of vehicles authorized).

Commissioner of Homeland Security and Emergency Services

DHSES USE

ONLY

Vehicle ID # (VIN)

MV-653EM (4/15)

Description of Vehicle(s)

YEAR MAKE MODEL VIN

PLATE NUMBER

(if currently registered)

COUNTY OF

PRIMARY USE