Fillable Printable Mv Self Cert Volunteer Ambulance Attendant Plates
Fillable Printable Mv Self Cert Volunteer Ambulance Attendant Plates
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Mv Self Cert Volunteer Ambulance Attendant Plates
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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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