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PS2904-1 (11/2020)
VETERAN / MILITARY DISABILITY PLATESOTHER DISABILITY PLATES
VET SERVICE ORGANIZATIONS
Must provide membership card
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Driver and Vehicle Services
Visit us: drive.mn.gov
APPLICATION FOR DISABILITY PLATES
DISABILITY PLATES
DISABILITY LICENSE PLATES
Please list the disability parking certificate number issued to the vehicle owner for a PERMANENT physical disability
*If applicant does not have a Disability Parking Certificate for a PERMANENT disability, section I must be completed.
Long-Term, Short-Term, & Temporary certificate holders do not qualify for disability plates
If disabled person has two permanent certificates, check the box next to the one that has been surrendered
CRITICAL HABITAT DISABILITY PLATES
($30 annual contribution)
Standard Disability Plates (Passenger)
Motorcycle (vertical not available)
Moped
Special Disability Plates
Additional fees may apply
Anglers
Chickadee
Loon
Deer
Buck
Ladyslipper
Moose
Pheasant
Turkey
Support Our Troops ($30 annual cont.)
MN Golf ($30 annual cont.)
State Parks and Trails ($60 annual cont.)
Start Seeing Motorcycles ($15 annual cont.)
College University ($25 annual cont.)
School Name
Retired Firefighter - letter required
Retired Law Enforcement - letter required
Law Enforcement Memorial Association
Remember Victims of Impaired Drivers
World War II Vet (Service medal only)
Korean Vet (Service medal only)
Vietnam Vet (Service medal only)
Persian Gulf Vet (Service medal only)
Iraq Vet
Afghanistan Vet
GWOT Vet (select one)
Expeditionary Medal Service Medal
Laos (Allied Vet)
Silver Star Vet
Korean Defense Service Vet
Armed Forces Expeditionary Vet
Combat Wounded
Pearl Harbor Survivor
Woman Vet
Ex-POW
"Proud To Be A Veteran" ($30 one time cont.)
National Guard Ready Reserve
Bronze Star Vet
VFW
Disabled American Veterans
American Legion
#
#
Check one:
NEW DUPLICATE TRANSFER
Describe below the vehicle on which special plates will be used.
MAKE YEAR
CURRENT PLATE #
CURRENT STICKER
MONTH YEAR
When transferring special plates, describe below the vehicle on which the plates had been used.
MAKE
YEAR
SPECIAL PLATE #
MONTH YEAR
NAME OF APPLICANT
ADDITIONAL OWNER
List the contact information for the applicant. If not registered owner or primary driver, complete Section J.
DRIVER'S LICENSE/ID NUMBER
DATE OF BIRTH
DATE OF BIRTH
DRIVER'S LICENSE/ID NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
Policy Expiration Date (mm/dd/yyyy)Policy NumberCompany Name
INSURANCE: Minn. Stat. § 169.798(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:
PERSONALIZED?
(If yes, complete Sec. G)
Yes No
VEHICLE IDENTIFICATION NUMBER
VEHICLE IDENTIFICATION NUMBER
CURRENT STICKER
Page 1 of 5
SECTION A
SECTION B
SECTION C
SECTION D
SECTION E
SECTION F
SECTION G
(DD - 214 required)
($25 initial cont., $5 annual)
Print Form
PS2904-1 (11/2020)
If the vehicle owner is the custodial parent or guardian of a permanently disabled minor or legal ward, list name and date of birth of disabled person here:
Disabled Minor/ Ward
SECTION L
NOTICE: Personalized plates are limited to 5 characters for disability passenger plates.
Personalized disability motorcycle plates and weighted vehicles are limited to 4 characters.
(see instructions).
Explanation of choices:
NOTE: This MUST be completed or plates will not be issued.
List 3 personalized plates in order of preference:
REGISTRATION TAX
PLATE FEE
REPLACEMENT FEE
PERSONALIZATION FEE
PLATE TRANSFER FEE
CONTRIBUTION
STATE FILING FEE
TOTAL DUE
TECH FEE
WHEELAGE TAX FEE
1st
2nd
3rd
Page 2 of 5
SECTION H
SECTION K
Veteran dates of service and eligibility
Minnesota does not currently offer a reduced registration rate or a specific license plate for "Disabled Veterans". The Disabled American Veteran plates are
issued to members of the organization and does not denote disability.
CERTIFICATION OF EX-P.O.W. STATUS
I certify that the applicant was a member of the military forces of the United States who was captured, separated and incarcerated by an enemy of the United
States during a period of armed conflict.
RETIRED FIREFIGHTER VERIFICATION
A letter of authorization signed by the Fire Department Chief must be attached to the application for Retired Firefighter plate issuance.
"I certify that I was a member of the fire department identified below in good standing for at least 10 years and now retired"
Date
Signature
Department/Organization
SECTION I
SECTION J
SECTION M
TENNESSEN WARNING
What will happen if I do not provide the requested information?
You can refuse, however, DPS may consider your application incomplete and not issue disability plates.
Who will have access to the requested information?
DPS may disclose personal information when it relates to the operation or use of a vehicle or to public safety. The use of personal information relates to public
safety if it concerns the physical safety or security of drivers, vehicles, pedestrians or property. The personal information you provide to apply for disability plates
is classified by 18 U.S.C § 2721 and the Minnesota Government Data Practices Act, Minn. Stat. 13.69(1) and is subject to the disclosure in accordance with
these laws.
What is the purpose of supplying the requested information?
The Department of Public Safety ("DPS") collects the information on this form for identification and record keeping purposes as required by the Minnesota
Government Data Practices Act, Minn. Stat. § 13.04(2).
Am I required to provide the requested information?
You are not legally required to complete this form.
I certify the disability plates assigned to the previously described vehicle will be used only on that vehicle as long as it is in my possession.
I will notify the department when these plates are removed or transferred to another vehicle.
Applicant Signature
SECTION N
SIGNATURES
Applicant is primary driver, if not, primary driver must also sign.
Primary Driver
Signature
PS2904-1 (11/2020)
Page 3 of 5
MEDICAL STATEMENT – To be completed by health professional
Check which definition(s) the applicant meets to qualify for the disability license plates:
(Note: Condition must be permanent)
(IF CONDITIONS 6-9 ARE CHECKED, THE SPECIFIC DIAGNOSIS CAUSING THE DISABILITY MUST BE PROVIDED)
1. Applicant has a cardiac condition to the extent that the applicant's functional limitations are classified in severity as class III or class IV
according to standards set by the American Heart Association.
2. Applicant uses portable oxygen.
3. Applicant has an arterial oxygen tension (PAO2) of less than 60 mm/Hg on room air at rest.
4. The applicant is restricted by a respiratory disease to the extent that the applicant's forced (respiratory) expiratory volume for one second, when
measured by spirometry, is less than one liter.
5. The applicant has lost an arm or leg and does not have or cannot use an artificial limb.
6. Because of the disability, applicant must use a wheelchair or cannot walk without the aid of; a walker, cane, crutches, braces, a prosthetic device or
another person.
Please specify
7. Because applicant has a condition that would be aggravated to such an extent that walking 200 feet would be life threatening.
This condition is
SECTION O
8. The applicant cannot walk 200 feet without stopping to rest.
This condition is
9. The applicant cannot walk without a significant risk of falling.
This condition is
PLEASE NOTE:
Complete and accurate information regarding the disability must be provided. Conditions 6-9 must specifically identify the diagnosis causing disability.
“I certify, by my signature as a licensed physician, physician’s assistant, advanced practice registered nurse or chiropractor that (patient’s name)
, in my professional opinion is permanently disabled and meets the definition(s) I have checked above
and is entitled to the applied for license plates.”
Health professional Signature and Title: X_____________________________________
Print Name Address Phone Number
One set of disability license plates per owner or operator. An additional plate is allowed for display on a motorcycle and additional sets of disability plates may be
obtained with person from the MN State Council on Disability; a specific questionnaire is required. Disability plates are available for the custodial parents of a
disabled minor or legal guardians of a disabled individual.
PS2904-1 (11/2020)
TRANSFER OF DISABILITY PLATES: If the vehicle on which the disability plates are now being used is sold, complete this application if you wish to
transfer the disability plates to another vehicle. It is your responsibility to obtain regular plates for the vehicle on which the disability plates were used. If the
expiration month and year on your disability plates do not agree with the regular plates submitted, the disability plates must be adjusted.
INSTRUCTIONS FOR APPLICATION
Firefighter / Retired Firefighter (Section I ) plates, an authorization letter from the fire chief is required.
Sections A, D, E, and G must be completed.
Ex-POW plates, Section J must be signed by the Minnesota Commissioner of Veteran Affairs.
If applicant does not have a Disability Parking Certificate for a permanent disability; section O must be completed
Section J must be completed by custodial parent of a minor or legal guardian of a disabled adult.
CONTRIBUTION PLATES
Contribution fees are in addition to any plate fee and are not refundable.
“PROUD TO BE A VETERAN”: A one-time minimum contribution of $30 to benefit the WWII memorial fund is due with initial application. “Proud to be a Veteran”
plate contribution is due only at the time of initial application.
“SUPPORT OUR TROOPS”: The minimum annual contribution is $30. You may make an additional contribution by indicating the total amount in the space
provided on application.
CRITICAL HABITAT PLATES: The minimum annual contribution is $30. You may make an additional contribution by indicating the total amount in the space
provided on application. Indicate your design choice in the space provided on page one.
COLLEGIATE PLATES: The minimum annual contribution for collegiate license plates is $25 per year. You may make an additional contribution by indicating the
total amount in the space provided on application. Indicate your design choice in the space provided on page one. Please check with your institution of choice
regarding participation in the special plate program or dvs.dps.mn.gov.
Plate Contributions are collected at the time of initial application, and each time registration is renewed.
In order to prove eligibility, veteran applicants are required to present a copy of their separation papers (DD - 214 or equivalent) at the time of application.
State law requires that these discharges be certified (bearing a raised impression of a seal or a statement attesting to their authenticity).
“Ex-POW” may have plates for one vehicle and must have certification from the commissioner of veterans’ affairs.
ELIGIBILITY REQUIREMENTS FOR VETERAN PLATES
DATES OF SERVICE AND ELIGIBILITY
WORLD WAR II: Served between DECEMBER 7, 1941 & DECEMBER
31, 1946
KOREA: Served between JUNE 27, 1950 & JANUARY 31, 1955
VIETNAM: Served between JULY 1, 1961 & JUNE 30, 1978
PERSIAN GULF: Served after August 1, 1990 during operation Desert
Storm, Desert Shield or any other military operation in the Persian Gulf.
IRAQ: Honorably discharged recipient of the Iraq Campaign Medal
AFGHANISTAN: Recipient of the Afghanistan Campaign Medal
GLOBAL WAR ON TERRORISM VETERAN (GWOT): Recipient of the
Global War on Terrorism Expeditionary Medal or the Global War on
Terrorism Service Medal. Please note which design is requested
LAOS (Allied Vet): Non-US Military who Served in the Laos War after
July 1, 1961, and before July 1, 1978. Certification required
SILVER STAR / BRONZE STAR
Applicant must provide dd214 or other documentation to show they have
been awarded the Corresponding Service Medal
COMBAT WOUNDED: Awarded the Purple Heart (May still be in active service)
“PEARL HARBOR SURVIVOR”: Stationed on the island of Oahu or offshore on
December 7, 1941 “Pearl Harbor Survivor” must have proof of eligibility for
membership in a Pearl Harbor survivor’s organization.
EX-POW: Must be certified by commissioner of veteran affairs.
MEDAL OF HONOR: Awarded the Medal of Honor
WOMAN Veteran: Honorably discharged veteran from any branch of the armed
services (available starting 01/01/2015)
“PROUD TO BE A VETERAN”: Honorably discharged from any branch of the
armed services.
Ready Reserve: Member or retired member of the United States Armed Forces
Ready Reserve
National Guard: Regularly enlisted, commissioned, or retired member of the
Minnesota National Guard
VFW / American Legion / DAV: Applicant provides membership card
KOREAN DEFENSE SERVICE/ ARMED FORCES EXPEDITIONARY:
Applicant must provide DD - 214 or other documentation to show they have
been awarded the Corresponding Service Medal
DISPOSAL OF PLATES: It is the responsibility of the applicant to properly dispose of any valid license plates assigned to the vehicle on which the special
license plates will be displayed when the plates have been received. For your convenience, these plates may be returned to a deputy registrar for recycling.
NOTICE: All data collected on a motor vehicle application is required by law. All disability information is considered private by law.
FEES: When returning this application by mail, the required fees, including filing fee must be included.
If you have further questions, contact the Driver & Vehicle Services Division at (651) 297-3166.
One set of disability license plates is allowed per owner or primary operator; An additional set of disability plates may be allowed by filling out the questionnaire
from the State Council on Disability and attaching it to the application for review. No additional information is needed if the additional plate request is for a
Motorcycle. Disability plates may be issued to a custodial parent or guardian of a permanently physically disabled minor (until age 18) or legal ward as defined in
section 524.5-102(17).
Page 4 of 5
PS2904-1 (11/2020)
NEW PERSONALIZED PLATES
Personalized plates are special plates issued to the owner of a motor vehicle for use only on that vehicle. Plates must have at least one letter but not more than
seven characters total (a character is an upper-case letter, space, hyphen, or number.); a personalized plate may not display all numbers. Disability passenger
plate is limited to 5 characters, disability motorcycle is limited to 4 characters. A vertical Motorcycle plate is not available with the disability plates. One space or
hyphen may be placed between adjoining characters (will be counted as a character, a space cannot be the first character). A personalized plate that offends
public morals or decency may not be issued. Personalized plates cannot duplicate other existing plates or any plates in a numbering system used or reserved by
the Driver and Vehicle Services Division.
The characters 1 (one) and I (the letter "I") and Ø (naval zero), 0 (zero) and O (oh) are deemed to be the same and may not be
duplicated to create new combinations (e.g. “TIM and “T1M” are the same).
When you transfer (sell) a motor vehicle, you may leave the plates on the transferred (sold) vehicle. You will lose the rights to those plates and the buyer of that
motor vehicle will assume the rights. Please submit a statement that the plates are to remain with the vehicle.
You may transfer the personalized plates to another motor vehicle registered in your name. You must complete another personalized plate application showing
the description of the vehicle on which the personalized plates will be displayed. It is your responsibility to obtain regular plates for the motor vehicle on which the
personalized plates were used.
If you are transferring the plates to a different class vehicle, (e.g., transfer from passenger class to gross weight class) new plates are required and must fit the
number of characters allowed for that new plate type.
TRANSFER OF PERSONALIZED PLATES
If you wish to retain the privilege of your combination you must keep current registration on the vehicle that the plates are displayed on as stated in Minn. Stat. §
168.12(2a). If you fail to maintain registration, you may lose your rights to that combination.
If you do not have another vehicle to place your personalized plates on, you may submit a letter requesting an extension (not to exceed one year) of your rights to
that combination or you may lose your rights to that combination. All correspondence must be submitted to the Division at the address listed on the front of this
form.
RETENTION OF YOUR PERSONALIZED PLATES (Minn. R. 7403.0950)
Page 5 of 5
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MINNESOTA DEPARTMENT OF PUBLIC SAFETY Visit us: drive.mn.gov (Minnesota Auto & Driver's License of Brainerd)

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Completed 27 February 2021

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