Fillable Printable Vtr 421 Application For Military Meritorious Service License Plates

Vtr 421 Application For Military Meritorious Service License Plates

Application for Military

Meritorious Service

License Plates

For County Use Only

License No

Mo/Yr of Exp

Date Issued

Instructions

Submit the completed application; payment (if personalized) in the form of a personal check, money order, or cashier’s check; and proof of

eligibility to the department at the following address:

Texas Department of Motor Vehicles

Vehicle Titles and Registration Division

Specialty Plates Unit

4000 Jackson Avenue

Austin, TX 78731

There are no registration or specialty plate fees for the first set of plates. To order additional sets of plates, the annual registration fee must be

paid to your local county tax assessor-collector. There is no specialty plate fee for additional sets.

Plates may be personalized for an additional $40 fee; make your choice on page 2. Do not mail cash. The personalization fee will not be

refunded once the application is submitted. Contact the Specialty Plates Unit at (512) 374-5010 if you have any questions.

Applicant Information

First Name

Middle Name

Last Name

Suffix

County

Address

City

State

ZIP

Phone Number

Vehicle Information

Vehicle Identification Number

Current TX Plate

Year

Make

Body Style

Empty Weight (lbs.)

 Passenger Car  Truck (up to 18,000 lbs.)  Motorcycle/Moped

 Air Force Cross  Distinguished Flying Cross  Legion of Merit

 Air Medal  Distinguished Flying Cross with Valor  Meritorious Service Medal

 Air Medal with Valor  Distinguished Service Medal Air Force  Navy and Marine Corps Medal

 Airmen’s Medal  Distinguished Service Medal Army  Navy Cross

 Army Distinguished Service Cross  Distinguished Service Medal Coast Guard  Prisoner of War Medal

 Bronze Star  Distinguished Service Medal Navy  Silver Star

 Bronze Star with Valor  Distinguished Service Medal Dept. of Defense  Soldier’s Medal

 Defense Meritorious Service Medal  Distinguished Service Medal Dept. of Homeland Security  Coast Guard Medal

 Defense Superior Service Medal  Distinguished Service Medal Dept. of Transportation

Certification – State law makes falsifying information a third degree felony.

I meet the eligibility requirements as listed on page 2 of this application and am providing proof to that effect.

Indicate if you are an unmarried surviving spouse:

 Unmarried Surviving Spouse

Signature Date

Form VTR-421 Rev. 9/2017 Form available online at www.TxDMV.gov Page 1 of 2

Plate Type – All plates are available for passenger cars, trucks (up to 18,000 lbs.), and motorcycles/mopeds.

General Requirements

• Texas title and vehicle registration must be in your name.

• If the plate is to be registered to a vehicle that is not titled in your name, attach a statement to this application stating that you have

legal right of possession and control of this vehicle at all times.

• If you recently filed an application for title, attach a copy of the title application receipt (VTR-500-RTS).

• Joint vehicle ownership between you and a spouse is permissible.

• Submit a separate application for additional vehicles to your local county tax assessor-collector’s office with the annual registration

fee.

• If the vehicle is leased, attach a copy of the lease agreement.

• Vehicle is for personal use only.

Eligibility Requirements - This application is for non-Disabled Veteran registration.

• Active members must provide a copy of their military ID and proof that they are a recipient of the medal being applied for, such as an

Officer Record Brief or Enlisted Record Brief.

• Former members must provide proof of their honorable discharge and proof that they are a recipient of the medal being applied for,

such as, a DD214.

• Prisoner of War Medal applicant must provide an official United States government document or certification from the United States

Department of Veterans Affairs certifying or identifying the applicant as a former prisoner of war.

• As an unmarried, surviving spouse of a veteran who had or was eligible for Meritorious Service license plates, you are eligible to

register your vehicle with a plate featuring the same military emblem. To apply, you must enclose a written statement that you are

unmarried and provide proof your spouse is deceased. A new plate will be issued with the same emblem and a new plate number.

Indicate your eligibility as a “Surviving Spouse” by checking the box on page 1.

Personalize Your Plate – If you would like to personalize your specialty plate, there will be a $40 fee per year,

in addition to the annual registration fee (if required).

• Show personalizations exactly as you want them to appear on your license plate(s). You may list more than one option in the event

the personalization you have chosen has been issued.

• A personalization that has been issued, is deemed offensive, or conflicts with the regular license plate numbering system cannot be

approved.

• Enter your desired personalized letters, numbers, and/or symbols in the blocks below. The available symbols include: a period,

a dash, a blank space, a Texas silhouette (use an asterisk “*” to indicate), a heart (use an at “@” to indicate), and a star (use an

ampersand “&” to indicate).

• Passenger car and truck plates are limited to six (6) characters total, including punctuation characters.

• Motorcycle/moped plates are limited to four (4) characters total, including punctuation characters.

• You are not required to use all the blocks provided.

• The International Symbol of Access “ “ counts as two (2) characters and will be located at the beginning of the plate number.

If you are disabled and applying for personalized specialty plates, use a percent “%” to indicate the International Symbol of Access.

Personalization fee will not be refunded once the application is submitted.

Choice 2

Choice 3

Choice

Vehicle 1

Vehicle 2

International Symbol of Access

To display the International Symbol of Access on your license plate, attach a signed Application for Persons with Disabilities Parking Placard

and/or License Plate (Form VTR-214) to this application to show your eligibility. Contact your county tax assessor-collector’s office if you have

questions.

Form VTR-421 Rev. 9/2017

Form available online at www.TxDMV.gov Page 2 of 2