OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES APPLICATION FOR REGISTRATION OF A MOTOR VEHICLE WITH RESTRICTED PLATES TYPE OR PRINT REGISTRATION INFORMATION FOUND ON VALID OHIO/OUT-OF-STATE REGISTRATION CARD LICENSE PLATE # EXPIRATION DATE BMV VALIDATION BLOCK STATE VEHICLE INFORMATION FROM OHIO CERTIFICATE/MEMORANDUM TITLE VEHICLE SERIAL NO. MAKE YEAR TYPE CERTIFICATE OF TITLE NO. (OHIO ONLY) OWNER INFORMATION OWNER NAME SOCIAL SECURITY NO. OR TAX ID NO. RESIDENCE ADDRESS CITY JOINT OWNER NAME STATE ZIP CODE COUNTY OF RESIDENCE OWNER MAILING ADDRESS CITY FILL IN CITY NAME ONLY IF INCORPORATED CITY YOU LIVE INSIDE CORPORATION LIMITS Y/N Y/N Is Your License Plate Registration Under Suspension or Revocation Under the Ohio Financial Responsibility Law? OWNER SIGNATURE FILL IN TOWNSHIP ONLY IF YOU LIVE OUTSIDE CORPORATION LIMITS Y/N Has the Motor Vehicle Being Registered been Operated by the Owner on Public Roads or Highways Prior to Date of This Application? STATE ZIP CODE TOWNSHIP If Operated by the Owner on Public Roads or Highways Prior to this Date, have Required Registration or transfer Fees Been Paid? DATE X COURT NOTIFICATION MUST BE COMPLETED BY TRIAL COURT AN APPLICATION FOR RESTRICTED PLATES HAS BEEN SUBMITTED BY THE FOLLOWING NAMED INDIVIDUAL: DEFENDANT RESIDENCE STREET CITY STATE ZIP CODE INDICATE BELOW THE ACTION TO BE TAKEN: Application APPROVED DISAPPROVED by Authorized Official COURT as submitted by , State of Ohio. in the County of Date Suspended or Revocation Expires DO NOT WRITE BELOW THIS LINE FOR BMV USE ONLY LICENSE NUMBER YEAR TYPE ENTERED ON RECORDS DATE FEE BY BMV 5761 10/07 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com COURT NOTIFICATION AND APPLICATION FOR OHIO RESTRICTED LICENSE PLATES When the license of any person is suspended or revoked, the trial judge may impound the Ohio registration and Ohio license plates of any motor vehicle the individual owns. Whenever an Ohio registration and license plates have been impounded in accordance with Ohio Revised Code Section 4507.02, the vehicle owner, with court approval, may apply for restricted license plates. (Ohio Revised Code Sections 4507.164, 4503.231, 4507.02). To obtain restricted license plates the following items MUST BE PRESENTED: 1. Payment due: Plate, $2.75 and Deputy Fee. 2. Completed and signed APPLICATION on REVERSE SIDE. 3. Trial Court must complete and sign COURT NOTIFICATION ON REVERSE SIDE. 4. OHIO Certificate of Title/Memorandum Title or current Registration Card is required. (COPIES NOT ACCEPTABLE). 5. This completed form must be taken to your local Deputy Registrar. IMPORTANT: Restricted license plates can only be issued to a vehicle with a current registration. For new Ohio license plates the original Certificate of Title/Memorandum Title is required. BMV 5761 10/07 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com