MV117 (2/20)
Sponsor Organization’s
Annual Certification for
Specialty License Plate
Office Use Only
P.O. Box 201431 Helena, MT 59620-1431 Fax (406) 444-2086 Email
Organizations are required to complete an annual certification and submit supporting documentation.
Section 1: Sponsor Organization Information
Sponsor name:
Telephone number:
Tax ID number:
Mailing address:
Physical address:
Section 2: Sponsor Liaison
Printed name of sponsor liaison:
Liaison telephone number:
Email address:
Liaison mailing address:
Section 3: Sponsor Organizations
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
1. Is the sponsor required to register with the Montana Secretary of State (SOS)?
a. If yes, the sponsor is in good standing with SOS?
2. Is the person listed as the liaison is authorized to act as the sponsor’s liaison?
3. Is the sponsor organization a tax-exempt organization under 26 U.S.C. 501(c)(3)
4. Is the sponsor organization required to file an annual tax filing documents, including
990N, 990EZ, 990PF, or 990
a. If no, why not?
5. Is the sponsor organization of service to the community through specific programs that
promote improving health, education, or general welfare?
a. If no, is the sponsor organization comprised of military service veterans?
6. Headquarters or base of operations:
a. Is the sponsor headquarters or base of operations in this state?
If no, describe:
MV117 (2/20)
b. Is the sponsor a chapter or branch of an international, national, or regional
organization, the chapter or branch is in good standing and has authorization in writing
from the parent organization to use the name and graphic of the parent organization
If no, describe:
Yes No
Yes No
7. Is the sponsor a Montana entity?
8. Does the sponsor have an active telephone number?
9. Are 75% of the donation fees collected for generic plates spent in Montana?
10. In the last calendar year, the sponsor collected $__________________ in generic
specialty plate fees.
a. In the last calendar year, the sponsor spent $_______________ of the generic
specialty plate fees collected in Montana.
11. The name, identifying phrase, and graphic on the generic specialty license plate
a. Is the sponsor authorized to use them?
b. Is there any infringement or violation of any property right in the use of them?
Yes No
Section 4. Required Documents Enclosed with Certification
You must enclose the following documents with your annual certification form.
Do NOT staple your documents.
Copy of current Montana Secretary of State’s certificate of good standing
Copy of IRS determination letter
Copy of current federal income tax filing documents
IRS Form 990N, 990EZ, or 990PF, or 990
Other: ________________________________
Organization is not required to submit annual tax filing documents.
List of current board of directors, positions, and contact information.
Additional Documentation showing 75% of collected fees from Specialty License Plates were spent
in Montana for last calendar year.
Balance Sheet
Profit and loss statement
Attach form MV117A describing how the money collected by the Specialty License Plate was
spent and detailing whether it was spent in or outside of Montana
MV117 (2/20)
Section 5. Required Documents Faxed to Motor Vehicles Division
Do NOT submit with your certification.
The following documents must be submitted by FAX ATTN: Specialty Plates to 406.444.2086
Proof of Montana banking institute.
page of most recent bank statement showing sponsor name, address, date, banking institution’s
name, and account number.
REDACT all financial information from this page, including balances, debits and credits.
I understand and accept MCA 61-3-472 through 61-3-481 Specialty License Plate requirements.
I have reviewed my organization's information as listed on the Motor Vehicle Division's website and no updates are needed at this time. If
updates are needed, submit form MV120.
Under penalty of law (MCA 45-7-203), I certify that the statements
made and information contained
on this form, the attached form, and banking statements are true and correct to the best of my
knowledge, information, and belief; I am the person named on this form; and, if signing for a business
entity or trust, I have full authority to do so.
Dated this
day of
, 20
Legal signature
Printed name
For office use only
The annual certification for sponsorship is approved.
MVD Coordinator Signature/Date
The annual certification for sponsorship
is rejected for the following reason:
Section 6. Indemnification Section:
Section 7. Certification Section:
The Sponsor agrees to indemnify, hold harmless, and release DOJ/MVD and their officers, agents
and employees from and against all loss, damages, injury, liability, suits and proceedings arising
from the use of the name, identifying phrase, and graphic on the generic specialty license plate,
including but not limited to any loss, damages, injury, liability, suits or proceedings from the use of
the name, Identifying phrase, and graphic.