First Name Middle Name Last Name Suffix County
Address City State ZIP
Email Phone Number
Passenger car Truck (up to 18,000 lbs.) Motorcycle/Moped
Gold Star Family Gold Star Father Gold Star Mother Gold Star Spouse
Date
Gold Star
License Plates
License No
Mo/Yr of Exp
Date Issued
Instructions
Submit the completed application; payment in the form of a personal check, money order, or cashier’s check; and proof of
eligibility to your local county tax assessor-collector’s office. Registration fees must be paid to establish a single expiration date
for both the specialty plate and the vehicle registration when your plates are issued; however, there is no specialty plate fee.
Plates may be personalized for an additional fee of $40; make your selection on page 2. The personalization fee is non-
refundable.
There is a limit of one Gold Star specialty plate per applicant. Gold Star plates are available for passenger cars and trucks (up to
18,000 lbs.) and motorcycles/mopeds.
The vehicle must h ave a title and registration in your name. If the vehicle is not titled in your name, attach a statement stating you
have legal right of possession and control of the vehicle. If you recently submitted an application for title, attach a copy of the title
application receipt (VTR-500-RTS). If the vehicle is leased, attach a copy of the lease agreement.
If you place your order by mail, please contact your county tax assessor-collector’s office in three weeks to verify your plates are
ready, or if you have any questions.
Plate Eligibility
You must submit proof of eligibility for the plate type you are requesting.
• Gold Star Family: Proof that you an immediate family member (parent, child, or sibling) of a person who died whil
e
s
erving in the U.S. Armed Forces
.
• G
old Star Father: Proof that you are the father of a person who died while serving in the U.S. Armed Forces
.
• G
old Star Mother: Proof that you are the mother of a person who died while serving in the U.S. Armed Forces
.
• Gold Star Spouse:
Proof that you are the surviving spouse of a person who died while
serving in the U.S. Armed Forces.
Applicant Information
Vehicle Information
Vehicle Identification Number Year Make
Vehicle Type
Plate Type
Certification – State law makes falsifying information a third-degree felony.
I certify I am eligible for the specialty license plates selected above and am providing proof to that effect.
Signature
Form available online at www.TxDMV.gov
