New York State Department of Motor Vehicles MV-653 (8/08) POLITICAL SUBDIVISION CERTIFICATION OF ELIGIBILITY FOR OFFICIAL PLATES ATTENTION: This form is to be used only by NYS political subdivisions to certify eligibility for Official plates. A political subdivision is defined as a subdivision of New York State that has been delegated certain official functions of state or local government, including a government entity created by, or under the authority of, State law. A vehicle assigned Official plates must be owned or controlled by a political subdivision and operated by its employees, or specifically designated agents thereof, in the course of their official duties. The vehicle must be titled and/or registered in the name of the political subdivision. Volunteer organizations are not political subdivisions, and must use form MV-653V. PLEASE CHECK THE APPROPRIATE BOX BELOW TO INDICATE YOUR OFFICIAL GOVERNMENT STATUS: GOVERNMENT DIVISION, DISTRICT OR OTHER GOVERNMENT ENTITY: State of New York County City Town Village School District Fire District Other Government Entity Name of NYS Agency, County, City, Town, Village, District or Other Government Entity Department or Division Address Name of Department or Division Director Business Phone Business E-Mail Address (Optional) DESCRIPTION OF VEHICLE(S): Check this box if you are certifying multiple vehicles, and attach a separate sheet listing the requested information for all vehicles. Year Make Model Vehicle ID # (VIN) Plate Number (if currently registered) CERTIFICATION I certify that the above-described vehicle(s) is (are) owned or controlled by the political subdivision to which this application for registration applies, and that the information contained herein is true and accurate. I do so in my capacity as a duly appointed public officer or official who has been granted the authority to act on behalf of the above-named political subdivision. I understand that knowingly making a false statement on an application submitted to the Commissioner of Motor Vehicles is a misdemeanor under Vehicle and Traffic Law, a misdemeanor or felony under New York State Penal Law, and may result in criminal prosecution in addition to revocation or suspension of the registration pursuant to regulations promulgated by the Commissioner of Motor Vehicles. Signature ± __________________________________________________________ Date:____________________________ (Sign Your Name in Full) Print Your Name: ______________________________________________ Title: ____________________________________ Address: ______________________________________________________________________________________________ City: _______________________________________________________________ Zip Code: __________________________ OFFICE USE ONLY Your Business ( ) Phone number ______________________________ Authorization Code ______________________ Your Business E-Mail Address (optional): ____________________________________ Code from List Code from IOCU DMV Supervisor Approval: _________________________________________________ Date: ___________________ (Signature) American LegalNet, Inc. www.FormsWorkFlow.com