CUSTOM PLATE ORDER
KANSAS
AND
DEPARTMENT OF REVENUE
DIVISION OF VEHICLE
LOST, STOLEN, REPLACEMENT, EXCHANGE
Topeka, Kansas 66626-0001
PLATE &/or DECAL APPLICATION
www.ksrevenue.gov/dmv
County Number County Name Application Date
TRANSACTION TYPE (Check All that Apply)
Lost Plate
Lost Decal
Stolen Plate Replacement Plate
Stolen Decal Replacement Decal
Special Plate App
Special Plate Exchange
Disabled Parking Placard
Special Interest Collector’s Number
Current Vehicle Type Current Registration Type
Current Plate No. Current Decal No.
OWNER’S NAME (Last, First, Middle Initial)
Registration Expiration Date
Relationship
Street City
VEHICLE INFORMATION
Year Make VIN
Model Style Gross Weight
LOST / STOLEN / REPLACEMENT / EXCHANGE INFORMATION
Reason:
New: Plate No. Decal No. Vehicle Type
SPECIAL PLATE APPLICATION:
State Zip
Truck Class
Registration Type
Choices: 1
st
2
nd
3
rd
4
th
ARO/FCC No.
Disabled Person's Name
Address
Special Interest No.
City State Zip
Disabled Parking Placard Type:
Permanent Temporary Expiration Date of Original Temporary Placard
INSURANCE
Company Name
Policy Number
I hereby certify that I am a resident or have a bona fide place of business
in this county and that I am an owner of and have in effect financial
security for the aforementioned vehicle as required by law. I further
certify that the information in this application is true and correct to the
best of my knowledge and belief.
FALSE CERTIFICATION CAN RESULT IN CRIMINAL
PROSECUTION
Owner's Signature(s)
Date
FEE SUMMARY
Personalized Plate Fee $
Decal Fee $
Reflectorized Plate Fee $
Replacement Plate Fee $
County Service Fee $
County Miscellaneous $
TOTAL $
Completed application is to be submitted to your
County Treasurer’s Motor Vehicle Office.
TR-211www (7-07) Original to DMV, Copy to Treasurer and Owner
