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Fillable Printable Tc-817 - Utah State Tax Commission

Fillable Printable Tc-817 - Utah State Tax Commission

Tc-817 - Utah State Tax Commission

Tc-817 - Utah State Tax Commission

This application is for a (check one):
New Order
Replacement
Your vehicle must have a current registration. Your vehicle must have a current registration.
The fee is $15 for a standard plate or $20 for a special group plate.
Section 1: Vehicle Information
Current Utah plate no. Date registration expires VIN Make Model Year
Section 2: Applicant Information
These plates will be
Date of application
placed on a (check one):
Motorcycle
Trailer
Automobile/truck/van/utility
Registered owner's name Daytime telephone number (required)
Mailing address Is this a new address?
Yes
No City State ZIP code
Section 3: Plate and Character Selection

Check one:
• Standard (use up to 7 characters) Motorcycle Standard (use up to 4 characters) Disabled Person (use up to 5 characters)

Life Elevated Arches ($60)
Life Elevated Arches ($60)
Life Elevated Arches ($65)

Life Elevated Skier ($60)
Life Elevated Skier ($60)
Life Elevated Skier ($65)
In God We Trust ($60)
In God We Trust ($60)
Disabled Standard ($65)
• Radio (use up to 6 characters)
Utah Special Group Plate
(use up to 5 characters)

Amateur Radio ($20)
On the line below, enter the plate type from the list on the following pages:
Search & Rescue Radio ($20)
Special plate type/name
Enter your choices below as you would like them displayed on your plate. Approved personalized plates will be made exactly as shown on
this form and are issued on a first-come, first-serve basis. For this reason, we encourage you to provide three unique choices, in order of
preference. If a choice is not available or not allowed under Utah Code §41-1a-411, we may consider your next choice. Do not use
special characters (period, apostrophe, dash, etc.).
1st Choice 2nd Choice 3rd Choice

Explain the meaning of these
Explain the meaning of these
Explain the meaning of these
characters: characters: characters:
I understand that my application for personalized plates is subject to availability and to the guidelines in Utah Code §41-1a-411. This
application will not be approved if it does not meet these guidelines. I also understand that acceptance of this application and payment of
fees does not mean my application will be approved.
Signature
X
You must pay the application fee plus any required contribution (special group plates only) with this application. Make your check or
money order payable to the Utah State Tax Commission. Mail the application and your payment to: Utah State Tax Commission, Division of
Motor Vehicles, Miscellaneous Services Unit, PO Box 30412, Salt Lake City, UT 84130.
TC-817
Rev. 11/17
Get forms at tax.utah.gov/forms
Utah State Tax Commission
Division of Motor Vehicles • PO Box 30412 • Salt Lake City, UT 84130 • 801-297-7780 or 1-800-368-8824
Application for Personalized Plates and
Replacement of Existing Personalized Plates
(only up to 5 characters)
(only up to 3 characters)
Clear form
.
.
.
.
Amateur Radio Provide a copy of a current FCC license with assigned call numbers. $20
Autism Awareness Annual contribution of at least $25 must be made in support of autism awareness programs. $90
Boy Scouts Annual contribution of at least $25 must be made to the Boy Scouts of America $90
Boys and Girls Club
Annual contribution of at least $25 must be made to Boys and Girls Club. $90
Cancer Research Annual contribution of at least $35 must be made in support of cancer research. $100
Children’s Issues Annual contribution of at least $25 must be made to the Guardian Ad Litem organization and $90
the Children’s Museum of Utah.
Collegiate Annual contribution in support of the selected school is required. The minimum annual contribution is: $90
$25 for the Dixie State University, LDS Business College, Salt Lake Community College, Snow College,
Southern Utah University, Utah State University, Utah Valley University, Weber State University, or Western
Governor’s University.
$30 for Westminster College. $95
$35 for Brigham Young University. $100
$40 for University of Utah. $105
Disabled Person Provide a complete form TC-842, Disabled Person and Physician Disability Certification $65
Disabled Veteran Provide a letter from the Utah Department of Veterans’ and Military Affairs or United States Military entity, $65
certifying the veteran’s disabled status. This plate does not qualify for parking in a disabled parking space.
Emergency Medical
Requires a certificate of current EMT training. $65
Technician (EMT)
Farm Truck This plate may be issued to trucks used exclusively to transport farm products or supplies. $65
Firefighter Annual contribution of at least $15 must be made to the Firefighter Support Fund. Provide any one of $80
the following: evidence of current membership in the Utah Firefighter’s Association; an official identification
card issued by a firefighting entity identifying the applicant as an employee or volunteer; or a letter on
letterhead from a firefighting entity or from the county/municipality in which the firefighting entity is located,
identifying the applicant as an employee, retired employee or volunteer of the firefighting entity.
Former Prisoner Provide a copy of Form DD214 or a Statement of Service from the Department of Veterans’ Affairs $65
of War (POW)
Gold Star Provide a document showing classification of death as listed by the U. S. Secretary of Defense, a casualty $65
report, a telegram from the U. S. Secretary of Defense, or another document that verifies the applicant is a
recipient of the Gold Star award.
Honoring Heroes Annual contribution of at least $35 must be made to the Public Safety Honoring Heroes foundation. $100
Humanitarian Service
Annual contribution of at least $25 must be made in support of various Utah humanitarian service organizations. $90
National Guard Provide copy of military photo ID. $65
No More Homeless Annual contribution of at least $25 must be made in support of No More Homeless Pets in Utah. $90
Pets
Pearl Harbor Survivor
Provide a copy of a membership card issued by the Pearl Harbor Survivors Association. $65
Public Education Annual contribution of at least $25 must be made to the Utah Association of Public School Foundations. $90
Support
Purple Heart Provide a copy of a membership card in the Military Order of the Purple Heart Association or military $50
discharge form DD214 issued by the National Personnel Records Center.
Soccer (RSL) Annual contribution of at least $25 must be made to the National Professional Men's Soccer Team Support of Building $90
Communities restricted account.
Search and Rescue
Provide a copy of a current Search and Rescue membership card, picture identification card, or a letter on $65
letterhead from a County Sheriff certifying that the applicant is a current member of a Search and Rescue team.
Search and Rescue
Provide documentation verifying call numbers from the county sheriff and a required item from the Search $20
Radio
and Rescue plate as shown above.
Plate type Plate Description & Contribution Requirements Fee
Personalized License Plate Descriptions and Fees
Rev. 11/17
Share the Road Annual contribution of at least $25 must be made to the Share the Road Bicycle Support Fund. $90
Snowmobiler Initial contribution of at least $25 must be made in support of snowmobile safety education programs. $90
No annual contribution is required.
Soil Conservation Initial contribution of at least $25 must be made in support of agricultural education programs. No annual $90
contribution is required.
Special Interest Vehicle must be 20 years old or older and must meet the requirements in Utah Code §41-1a-102(58). $65
Utah Jazz Annual contribution of at least $25 must be made to the National Professional Men's Basketball Team support $90
of women and children issues.
Utah Housing Annual contribution of at least $30 must be made in support of affordable housing programs. Provide proof of $95
Opportunity membership in a trade organization for real estate licensees which has more than 15,000 Utah members.
(Realtor)
Veterans Initial contribution of at least $25 must be made to the Utah Department of Veterans’ and Military Affairs. $90
An annual contribution of $10 must be made thereafter. Applicant may select the Air Force, American Legion,
Army, Coast Guard, Marines, or Navy plate.
Veteran Combat Initial contribution of at least $25 must be made to the Utah Department of Veterans’ and Military Affairs. $90
Theater An annual contribution of $10 must be made thereafter. Applicant may select the Army Combat Infantry Badge,
Army Combat Action Badge, Air Force Combat Action Medal, or the Marine & Navy Combat Action Ribbon.
Must obtain proof of qualification for the campaign or combat theater award requested from the Utah Department of
Veterans’ and Military Affairs.
Vintage Vehicle must be at least 30 years old and not driven for general daily transportation. $65
Wildlife Annual contribution of at least $25 must be made in support of wildlife and wildlife habitat preservation. $90
Applicant may select the Kestrel, Elk, Trout, or Mule Deer plate.
Zion National Park Annual contribution of at least $25 must be made in support of Zion National Park preservation. $90
All plates, except Amateur Radio, Search and Rescue Radio, and Purple Heart, require payment of an additional $10 fee when renewing for the
next registration year. Any personalized plate that has not been renewed within six months of its expiration date will be forfeited.
Plate type Plate Description & Contribution Requirements Fee
Personalized License Plate Descriptions and Fees
Rev. 11/17
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