New York State Department of Motor Vehicles STATEMENT TO REGISTER A VEHICLE WITH FORMER POW OR CONGRESSIONAL MEDAL OF HONOR PLATES Name: __________________________________________________________ Address: __________________________________________________________ Year and Make of Vehicle: __________________________________________________________ Body Type: __________________________________________________________ Vehicle Identification Number: __________________________________________________________ I want to register a vehicle in New York State and I certify that I: am a former prisoner of war, and that I am eligible to receive one set of “Former POW” license plates, as authorized by section 404-c of the NYS Vehicle and Traffic Law. have been awarded the Congressional Medal of Honor by the President of the United States, and that I am eligible to receive one set of “Congressional Medal of Honor” license plates, as authorized by section 404-p of the NYS Vehicle and Traffic Law. I intend to display the license plates noted above on this vehicle. I understand that I am exempt from paying registration fees for this vehicle once I apply for the license plates noted above. I also acknowledge that I can register only one vehicle (only one current registration) in New York State that displays the license plates noted above, and I certify that I do not currently have another vehicle registered in New York State with such plates. Signature of Customer: ± ______________________________________________________ MV-1H (10/07) www.nysdmv.com American LegalNet, Inc. www.FormsWorkFlow.com