OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES REGISTRATION INFORMATION and AUTHORIZATION to REGISTER TO BE COMPLETED BY THE OWNER OR PURCHASER OF VEHICLE(S) LISTED BELOW I, _____________________________________________ of __________________________________________________________________hereby Print Full Name of Vehicle Owner Print Address of Vehicle Owner appoint ________________________________________________ of ________________________________________________________________ Print Full Name of Person Granted Authority Print Address of Person Granted Authority to make application, in my stead, for registration or transfer of registration for the following vehicle(s): PLATE NUMBER VEH. YEAR MAKE TYPE COLOR VEHICLE OWNER DATE OF BIRTH VEHICLE OWNER OH DL#/OH ID# VEHICLE OWNER SSN (IF NO OH DL/OH ID) SERIAL NUMBER VEHICLE OWNER EIN/TIN FOR BMV USE ONLY/CLERK VERIFICATION OF VEHICLE OWNER LIST DOCUMENT W/ SSN VEHICLE OWNER PRESENTED OH DL/OH ID/MATCH IF NO OH DL/OH ID, PROOF OF SSN REQUIRED IN THE CASE OF A LEASE OR JOINT OWNERSHIP, YOU WILL BE REQUIRED TO PROVIDE THE LESSEE/ADDITIONAL OWNER’S OHIO DRIVER LICENSE NUMBER (DL), OHIO ID CARD NUMBER (ID), SOCIAL SECURITY NUMBER (SSN), TAX IDENTIFICATION NUMBER (EIN/TIN). LESSEE/ADDITIONAL VEHICLE OWNER NAME LESSEE/ADDITIONAL VEHICLE OWNER OH DL#/OH ID# LESSEE/ADDITIONAL VEHICLE OWNER SSN (IF NO OH DL/OH ID) LESSEE/ADDITIONAL VEHICLE OWNER EIN/TIN FOR BMV USE ONLY/CLERK VERIFICATION OF LESSEE OH DL/OH ID/MATCH IF NO OH DL/OH ID, PROOF OF SSN REQUIRED IDENTIFICATION OF PERSON GRANTED AUTHORITY (PGA) LIST DOCUMENT W/ SSN LESSEE PRESENTED PGA U.S./CANADIAN DL#/ID# PGA SSN (IF NO U.S./CANADIAN DL/ID IS AVAILABLE) FOR BMV USE ONLY/CLERK VERIFICATION OF PERSON GRANTED AUTHORITY CLERK’S INITIALS U.S./CANADIAN DL/ID (PGA can present U.S. or Canadian DL/ID) I certify I have reviewed documents to verify DL/ID or SSN. X SSN VIA ACCEPTABLE DOCUMENT I acknowledge that I (we), the owner(s), or lessees of leased vehicle now have insurance or other financial responsibility coverage covering this vehicle and I (we) will not operate or permit the operation of this vehicle without FR coverage, and that the vehicle will not be used as a commercial vehicle unless so registered. I understand and acknowledge that making false statements on this document is illegal and may subject me to criminal penalties. SIGNATURE OF OWNER(S) X COUNTY OF RESIDENCE DATE CITY OR TOWNSHIP OF RESIDENCE FOR LIST OF ACCEPTABLE DOCUMENTS, GO TO WWW.BMV.OHIO.GOV ACCEPTABLE DOCUMENTS LIST: FORM BMV 2424 YOU WILL LOSE YOUR DRIVER LICENSE FOR AT LEAST 90 DAYS IF YOU DRIVE WITHOUT INSURANCE OR OTHER ACCEPTABLE FINANCIAL RESPONSIBILITY COVERAGE 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 At all vehicle inspection stops Upon traffic court appearances and Upon random checks by the Registrar of Motor Vehicles. 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, and $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 (“Highrisk” 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 A SECURITY SUSPENSION for TWO YEARS or more and A JUDGMENT SUSPENSION INDEFINITELY (until all damages have been satisfied). 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. DETACH BOTTOM PORTION FOR YOUR RECORDS THIS COMPLETED FORM MUST BE ATTACHED TO THE BMV APPLICATION 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. of Motor Vehicles. ANY DRIVER OR OW fense, ONE YEAR on second offens reinstatement fees of $100.00 for first offense, $300.00 for second offense, and $600.00 for third and subsequent offenses uired to maintain special FR coverage (“Highrisk” 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 INVOLVE RITY SUSPENSION for TWO 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 COVE odily injury per amount of $30,000 on deposit with 10/10 FOR MONEY OR GOVERNMENT BONDS in the -INSURANCE, available only to companies or persons who own at least twenty-six motor vehicles. American LegalNet, Inc. www.FormsWorkFlow.com