MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES - LICENSE PLATE IMPOUND UNIT
445 Minnesota Street, Suite 166
Saint Paul, MN 55101-5166
Phone: (651) 297-5034 FAX: (651) 797-1810 TTY: (651) 282-6555
Web: dvs.dps.mn.gov
Application for Special Registration Plates
NEW PLATE # ISSUED
NEW YEAR VALIDATION # ISSUED
DEPUTY STAMP
PLEASE READ INSTRUCTIONS ON BACK BEFORE COMPLETING THIS FORM.
MAKEMODEL YEAR
VEHICLE IDENTIFICATION NUMBERCURRENT PLATE #
CURRENT EXP. DATE
MONTH / YEAR
NAME OF OWNER(S) (LAST, FIRST AND MIDDLE) DRIVER'S LICENSE NUMBER
PRINT PERMANENT ADDRESS: STREET CITY STATE ZIP CODE
PLATE YEAR TYPE
COUNTY
REGISTRATION TAX
SPECIAL PLATE FEE
FILING FEE
TOTAL DUE
PS2041-8 Rev. 12/15
-OVER-
NEW WEIGHT STICKER # ISSUED
FEES DUE
Name of Driver at Incident
(at time of incident)
Incident Date (mm/dd/yyyy) Date of Birth (mm/dd/yyyy)
If owner is valid or has a limited license they may use their information as qualified driver (a 7-day temp permit does not qualify)
If owner is not valid; a qualified driver must fill in the information and sign below.
I am requesting authorization to receive special registration plates for the above-described vehicle. Only a driver with a valid or limited license may use the
above-described vehicle with the special registration plates.
QUALIFIED DRIVER STATEMENT
Qualified licensed driver must sign here: X
I have a valid or limited driver’s license (Note: A 7-day temp. license or learners permit is not acceptable), and I know that a person may not drive, operate or
be in physical control of a vehicle without a valid or limited driver’s license.
DATE OF BIRTHQUALIFIED DRIVER'S FULL NAME DRIVER'S LICENSE NUMBER
Vehicle Owner:
I request authorization for special registration plates for the above-described vehicle. I do certify all of the declarations are true and correct.
I understand that only a driver with a valid or limited license may use the above-described vehicle with the special registration plates.
I know that no person may drive, operate or be in physical control of a vehicle without a valid driver’s license.
I understand that Special Registration plates must be displayed for a minimum of one year from the date of qualifying incident and where the
violator is also an owner, co-owner, or lessee of the vehicle; plates must be displayed until their driving privileges are fully valid, whichever
period of time is longer.
X
Vehicle Owner must sign here
Date
The month and year stickers you are replacing must match those originally on this vehicle. The application for plates must be completed by the
registered owner(s), and any remaining plates and/or stickers must be surrendered.
All data collected on a motor vehicle application is required by law. This data is used to identify your motor vehicle. Failure to provide required data may result
in denial of the transfer of ownership, registration of this vehicle, or other requested action.
IMPORTANT NOTICE: PLEASE READ
ZIP CODESTATECOUNTYCITYMAILING ADDRESS: STREET (if different than above)
Policy Expiration Date: (mm/dd/yyyy)
Policy Number:
INSURANCE: MN Statute 169.78 Subd. 4 Every owner, when applying for vehicle registration, re-registration, or transfer
of ownership, must provide information showing that the vehicle is covered by an insurance policy.
Required information consists of:
Company Name:
