OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES APPLICATION FOR SENIOR, TEMPORARY FARM AND CAMP BUS LICENSE PLATES You MUST CHECK THE TYPE of new plate requested or your application cannot be processed. SENIORS BUS TYPE OR PRINT TEMPORARY FARM BUS CAMP BUS INSTRUCTIONS ON BACK REGISTRATION INFORMATION FOUND ON OHIO REGISTRATION CARD OHIO LICENSE PLATE # EXPIRATION DATE VEHICLE INFORMATION FROM OHIO CERTIFICATE/MEMORANDUM TITLE DATE VEHICLE PURCHASED VEH YEAR MAKE TYPE VEHICLE SERIAL # CERTIFICATE OF TITLE # OWNER INFORMATION OWNER NAME DAYTIME PHONE # OHIO ADDRESS DATE OF BIRTH SSN/TIN/OH DL/OH ID CITY STATE ZIP CODE OH VEHICLE OWNERSHIP SINGLE JOINT LEASED OWNER BUSINESS ADDRESS JOINT OWNER/LESSEE NAME SSN OR TAX ID # OHIO COUNTY OF RESIDENCE COMPANY CITY STATE ZIP CODE Is your license plate registration under suspension or revocation under Ohio Financial Responsibility Law? YES: NO IF PLATES ARE TO BE MAILED TO A DIFFERENT ADDRESS FROM THAT SHOWN ABOVE, FILL IN THE FOLLOWING ADDRESS CITY STATE ZIP CODE PROOF OF FINANCIAL RESPONSIBILITY YOU WILL LOSE YOUR DRIVER LICENSE FOR AT LEAST 90 DAYS IF YOU DRIVE WITHOUT INSURANCE OR OTHER FR PROOF In Ohio, it is illegal to drive any motor vehicle without insurance or other financial responsibility (FR) coverage. It is also illegal for any motor vehicle owner to allow anyone else to drive the owner’s vehicle without FR coverage. PROOF OF COVERAGE IS REQUIRED: Whenever a police officer issues a traffic ticket random checks by the Registrar of Motor Vehicles. At all vehicle inspection stops Upon traffic court appearances and Upon ANY DRIVER OR OWNER WHO FAILS TO SHOW PROOF OF INSURANCE OR OTHER COVERAGE WILL: Lose his or her driver license for 90 DAYS on first offense, ONE YEAR on second offense and TWO YEARS on additional offenses Lose his or her license plates and vehicle registration Pay reinstatement fees of $100.00 for first offense, $300.00 for second offense, $600.00 for third and subsequent offenses Pay a $50.00 penalty for any failure to surrender his or her driver license, license plates, or registration AND Be required to maintain special FR coverage (“High-risk” insurance or equivalent) on file with the Bureau of Motor Vehicles (BMV) for THREE or FIVE YEARS. ONCE THIS SUSPENSION IS IN EFFECT: Any driver or owner who violates the suspension will have his or her vehicle immobilized and his or her license plates confiscated for at least 30 DAYS first offense and 60 DAYS second offense. For third or subsequent offenses, the vehicle will be forfeited and sold and the person will not be permitted to register any motor vehicle in Ohio for FIVE YEARS. IF YOU ARE INVOLVED IN AN ACCIDENT WITHOUT INSURANCE OR OTHER FR COVERAGE: In addition to all the penalties listed above, you may have SECURITY SUSPENSION for TWO YEARS or more and A JUDGMENT SUSPENSION INDEFINITELY (until all damages have been satisfied). A THESE PENALTIES ARE IN ADDITION TO ANY FINES OR PENALTIES IMPOSED BY A COURT OF LAW. WARNING: THESE LAWS DO NOT PREVENT THE POSSIBILITY THAT YOU MAY BE INVOLVED IN AN ACCIDENT WITH A PERSON WHO HAS NO INSURANCE OR OTHER FR COVERAGE. WHEN REQUIRED, PROOF OF COVERAGE MAY BE SHOWN BY ANY OF THE FOLLOWING: AN INSURANCE POLICY showing automobile liability insurance of at least $12,500 bodily injury per person, $25,000 injury two or more persons, and $7,500 property damage AN INSURANCE IDENTIFICATION CARD (same coverage) A SURETY BOND OF $30,000 issued by any authorized surety company or insurance company A BMV BOND SECURED BY REAL ESTATE having equity of at least $60,000: A BMV CERTIFICATE FOR MONEY OR GOVERNMENT BONDS in the amount of $30,000 on deposit with the Ohio Treasurer of State A BMV CERTIFICATE OF SELF-INSURANCE, available only to companies or persons who own at least twenty-six motor vehicles. I affirm that the owners (or lessees of leased vehicle) now have insurance or other proof of financial responsibility (FR Proof) covering this vehicle and will not operate or permit the operation of this vehicle without FR Proof; and will not be used as a commercial vehicle unless so registered. APPLICANT SIGNATURE DATE X WARNING: Applicant giving false information is subject to prosecution Ohio Revised Code (R.C.) 2913.42 Application must be signed by the owner(s) as named on Certificate of Title CERTIFICATE OF TITLE AND/OR EPA INSPECTED BY: DEPUTY REGISTRAR NAME/NUMBER Your application will be processed and new plates mailed within four weeks. Failure to follow instructions will delay the issuance of your license plates. OHIO BUREAU OF MOTOR VEHICLES, ATTN: REGISTRATION SECTION P.O. Box 16521, Columbus, Ohio 43216-6521 (614) 752-7800 or 1-800-589-2847 NOTE: YOU MUST HAVE YOUR VEHICLE INSPECTED ANNUALLY BY THE HIGHWAY PATROL IF YOUR VEHICLE IS MANUFACTURED TO TRANSPORT MORE THAN FIFTEEN (15) PASSENGERS, INCLUDING THE DRIVER, OR HAS A GROSS VEHICLE WEIGHT THAT EXCEEDS TEN THOUSAND POUNDS. BMV 4816 1/11 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS SENIOR BUS (R.C. 4503.04) Below affidavit must be completed. The owner of a bus used principally for the transportation of persons sixty-five years of age or older may obtain Seniors license plates. To qualify for Seniors bus license plates, the bus must seat 10 or more. TEMPORARY FARM BUS (R.C. 4503.04) Below affidavit must be completed. Temporary farm bus vehicle license plates can be issued for a period of ninety days. An additional set of plates can be purchased, if necessary, for another ninety day period. Such plates may not be issued for more than two (2) ninety-day periods in any licensing year. The bus will be used solely for the transportation of agricultural employees, and used only in transportation of such employees as are needed in the operation of the farm. Statement must be completed and signed by the owner(s) or lessee(s). CAMP BUS (R.C. 4503.17) Below statement and affidavit must be completed. The owner of a school bus under contract with a board of education may use such bus during summer vacation periods to transport children and their authorized supervisors to and from any camping function sponsored by a nonprofit, taxexempt, charitable, or philanthropic organization. Certificate for school bus from State Highway Patrol required. Required fee ADD Permissive Tax Deputy Registrar Fee Postage Total Amount Due $ $ $ $ $ MAILING INSTRUCTIONS ON REVERSE SIDE STATEMENT OWNER OF BUS OR NAME OF SCHOOL BOARD MAKE OF BUS STREET ADDRESS YEAR CITY COUNTY SERIAL # (CAMP BUS) Name: is under contract with this school board of education to transport school children either to and from school, or to and from any school function. SIGNATURE NAME OF SCHOOL BOARD OF EDUCATION (CAMP BUS) DATE X AFFIDAVIT MUST BE NOTARIZED OWNER OF BUS STREET ADDRESS YEAR/MAKE SERIAL # NAME OF LESSEE CITY STREET ADDRESS SCHOOL BUS LIC #: (CAMP BUS) CITY Applicant being first duly sworn states that the bus described above has a seating capacity of ten or more and (Check one) Will be used principally for the transportation of persons sixty-five years of age or older. Will be operated exclusively during the summer months to transport children and their authorized supervisors to and from any camping function sponsored by a nonprofit, tax-exempt, charitable or philanthropic organization. Will be used solely for the transportation of agricultural employees, and used only in the transportation of such employees as are necessary in the operation of the farm, for a ninety day period, beginning with the effective date of Temporary Farm Bus registration. Sworn to before me and signed in my presence this SIGNATURE OF OWNER(S) OR LESSEE(S) NOTARY PUBLIC day of , . MY COMMISSION EXPIRES X THE FOLLOWING ITEMS MUST BE RETURNED TO THE OHIO BMV TO REGISTER BY MAIL: 1. Total amount due. Make check or money order payable to: Ohio Treasurer Josh Mandel, BMV, Add permissive tax to total due if applicable. 2. The R.C. 4503.19 requires that you ADD $7.50 to the above fees for replacement plates if your vehicle is currently registered or has been registered within the last 12 months. 3. Current OHIO vehicle registration card for above vehicle. Temporary tag registration or registration card which expired more than 11 months ago is unacceptable. If registration card is unavailable, send Certificate of Title or Memorandum Title (original document only). You may take these documents to any deputy registrar agency. The deputy will verify the vehicle information for a service fee. 4. Required documents as stated ABOVE (see instructions) for the type of registration being requested. 5. Affidavit and/or statement must be completed. 6. Completed and signed application. Mailing address on front. BMV VALIDATE You are now permitted to donate $1.00 to the children’s Save Our Sight Program by checking the appropriate box below and adding an additional $1.00 to your total fees due. For more information on the children’s Save Our Sight Program, please call 1-800-755-GROW (4769). Yes, I would like to donate to the children’s Save Our Sight Program. I have added $1.00 to the total fees due. BMV 4816 1/11 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com