MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
OFFICE USE ONLY
Assigned Plate No.
Assigned Sticker No.
Weight Sticker No.
Gold Star License Plate Application
PAID STAMP
• Print and mail this completed application to Driver and Vehicle Services, 445 Minnesota Street,
St. Paul, Minnesota 55101-5164. It may also be submitted at Deputy Registrar offices statewide.
• If you have questions or need additional information, please contact DVS at (651) 297-3166.
• Gold Star Family plates are available to the parent, spouse, sibling or child of a person who has died while
honorably serving in active service. Funding is provided by the Minnesota Department of Veteran Affairs
through Support Our Troops license plate contributions.
• Applicant must provide DD1300 "Report of Casualty," DD2064 "Certificate of Death," or have
certification of eligibility from the Commissioner of Veteran Affairs.
• Except for certain uses permitted by federal and state laws, personal information contained in your
application may not be disclosed to anyone without your express consent. You may expressly
consent to the disclosure of your personal information by writing to the address above.
Gold Star Family License Plate
Type or Print Full Name of person who has died while honorably serving in active service
Darken your relation to the above-named person:
Spouse Parent Sibling Child
Describe below the vehicle on which the plates will be used:
Year/Make
Vehicle Identification Number
Current Plate Number
Expiration Date (MM/YY)
Print Name of Applicant/Owner
Driver's Date of Birth (mm/dd/yy)
Driver's License Number (omit dashes)
Print Name of Additional Owner
Driver's Date of Birth (mm/dd/yy)
Driver's License Number (omit dashes)
Address City/State/Zip
X
Signature
If special plates must be replaced, darken the reason below.
Lost
Never Received
Destroyed
Defective
Stolen
Damaged
REGISTRATION TAX
$
PLATE FEE
$None
TECH SURCHARGE (Due only with
renewal)
$
FILING FEE
$10
TOTAL DUE
$
PS2013-04 (07/15)
