Fillable Printable Form MV-653V - Volunteer Fire/Ambulance Company Certification of Eligibility - New York

Form MV-653V - Volunteer Fire/Ambulance Company Certification of Eligibility - New York

New York State Department of Motor Vehicles

VOLUNTEER FIRE COMPANY OR VOLUNTEER AMBULANCE COMPANY

CERTIFICATION OF ELIGIBILITY FOR OFFICIAL PLATES

I certify that the above-described vehicle(s) is (are) owned or controlled by the volunteer organization to which this application

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

has been granted the authority to act on behalf of the above-named organization.

I understand and agree that if, in the future, the above-described vehicle or my organization no longer meets the qualifications

listed (cited in the check boxes above), it is the above-mentioned organization’s responsibility to surrender the registration items

to the NYS DMV. Failure to surrender the registration items may result in the suspension of the registration.

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.

ATTENTION: This form is to be used only by a volunteer fire company or volunteer ambulance company to certify eligibility for

Official Plates for the vehicle types described in the check boxes below. The vehicle must be registered in the name of the volunteer

organization. THIS FORM CANNOT BE USED TO REGISTER AMBULANCES. Proof of vehicle insurance is required. You

must present a valid insurance card with this form.

Signature ± __________________________________________________________ Date: __________________________

Print Your Name: ______________________________________________ Title: ____________________________________

Address: ______________________________________________________________________________________________

City: _______________________________________________________________ Zip Code: __________________________

MV-653V (1/09)

(Sign Your Name in Full)

DESCRIPTION OF VEHICLE(S) (NO AMBULANCES SHOULD BE LISTED IN THIS SECTION):

PLEASE CHECK ONLY ONE BOX BELOW:

 Check this box if you are certifying multiple vehicles, and attach a separate sheet listing the requested information for all vehicles.

 This volunteer fire company is registering a fire vehicle, as defined in §115-a of the Vehicle and Traffic Law, which is owned

or controlled by a fire company, as defined in §3 of the Volunteer Firefighters’ Benefit Law.

 This volunteer ambulance company is registering an Emergency Ambulance Service Vehicle (EASV), as defined in §115-c

of the Vehicle & Traffic Law, which is owned or controlled by an ambulance company, as defined in §3 of the Volunteer

Ambulance Workers’ Benefit Law.

CERTIFICATION

Year

Vehicle ID # (VIN)

Make Model

Plate Number (if currently registered)

 FS Insurance Card Presented

Insurance Company Code_________________

Insurance Effective Date __________________

VOLUNTEER FIRE OR VOLUNTEER AMBULANCE ORGANIZATION INFORMATION

Name of Volunteer Organization

Address

Head of Organization Title

Business Phone Business E-Mail Address (Optional)

DMV Supervisor Approval: _________________________________________________ Date: ___________________

Authorization Code ______________________

 Code from List

 Code from IOCU

(Signature)

OFFICE USE ONLY