Fillable Printable Mv Self Cert Volunteer Ambulance Attendant Plates

Mv Self Cert Volunteer Ambulance Attendant Plates

SELF CERTIFICATION FOR VOLUNTEER AMBULANCE ATTENDANT PLATES

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

DRIVER AND VEHICLE SERVICES

445 Minnesota Street, St. Paul, MN 55101-5164

Phone: (651) 297-3166 TTY: (651) 282-6555

Web: dvs.dps.mn.gov

PS2010B (08/14)

Minnesota Department of Public Safety

Driver and Vehicle Services Division

Special Plates Unit

445 Minnesota St. Ste. 164

St. Paul, MN 55101

I certify that I am an active member of the fire department or organization for volunteer ambulance attendants (as defined in Minn. Stat. 144e

01, Subd. 15) identified below;

Subd. 15.Volunteer ambulance attendant.

"Volunteer ambulance attendant" means a person who provides emergency medical services for a Minnesota licensed ambulance

service without the expectation of remuneration and who does not depend in any way upon the provision of these services for the

person's livelihood. An individual may be considered a volunteer ambulance attendant even though the individual receives an hourly

stipend for each hour of actual service provided, except for hours on standby alert, or other nominal fee, and even though the hourly

stipend or other nominal fee is regarded as taxable income for purposes of state or federal law, provided that the hourly stipend and

other nominal fees do not exceed $6,000 annually.

I will immediately notify the department of Public Safety upon the termination of my membership in this department or organization.

Department/Origin:

Signature:

Date:

Submit completed form to:

Instructions: Complete the Application for Special Plates (PS2010) and this Self-Certification for Volunteer Ambulance Attendant Plates form

(PS2010B), an addendum to the Application for Special Plates.

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