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MV-141 (4-18) |
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SURRENDER OF A REGISTRATION PLATE |
Bureau of Motor Vehicles • 1101 S. Front Street • Harrisburg, PA 17104 |
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www.dmv.pa.gov |
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For Department Use Only |
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Registration Plate Must be Attached |
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A |
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Applicant and Vehicle Information |
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NOTE TO VEHICLE OWNER: You must retain a copy of this receipt in order to obtain a replacement registration plate from an authorized agent. |
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Name of Registrant |
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Registration Plate Number |
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Title Number |
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B |
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The above registration plate is being returned to PennDOT for the following |
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reason(s): |
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1.q Replacement of Registration Plate |
5. qMoved Out-of-State |
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9. |
qTermination or Lapse of Insurance |
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2.q Vehicle Sold (no plate needed) |
6. qInsurance Stop |
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10. qRegistration Privileges Suspended |
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3. q Voluntary Surrender |
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7. qVehicle Deal Cancelled |
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11. qOther:____________________________ |
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4. q Personalized Registration Plate - Issued _____ 8. qExchange Registration Plate Issued |
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C |
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Decentralized Service or Full Agent Information (If applicable) |
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The registration plate listed above was surrendered on _______________ to the authorized agent below: |
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Decentralized Service or Full Agent Name |
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Date |
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Street Address |
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I certify that I have verified that the number listed on the registration plate matches the registration plate number listed above and hereby certify |
under penalty of law that |
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ALL information contained herein is TRUE and CORRECT and that I understand that any misstatement of fact is a misdemeanor of the third degree punishable by a fine |
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up to $2,500 and/or imprisonment up to 1 year (18 Pa.C.S. Section 4904[b]). |
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______________________________________________________ |
______________________________________________________ |
_________________________ |
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Printed Name of Authorized Agent |
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Authorized Agent Signature |
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D |
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Law Enforcement/PennDOT Locations |
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The registration plate listed above was surrendered on _______________ to the authorized agent below: |
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Law Enforcement/PennDOT Location Name |
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Date |
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Street Address |
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I certify that I have verified that the number listed on the registration plate matches the registration plate number listed above and hereby certify |
under penalty of law that |
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ALL information contained herein is TRUE and CORRECT and that I understand that any misstatement of fact is a misdemeanor of the third degree punishable by a fine |
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up to $2,500 and/or imprisonment up to 1 year (18 Pa.C.S. Section 4904[b]). |
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______________________________________________________ |
______________________________________________________ |
_________________________ |
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Printed Name of Authorized Person |
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Authorized Person Signature |
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E |
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Registration Plate Owners |
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I/We are surrendering the above listed registration plate to the Department on _______________. |
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Registration Plate Owner Name |
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Date |
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Street Address |
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I/We certify that I/we have verified that the number listed on the registration plate matches the registration plate number listed above and hereby |
certify under penalty of law |
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that ALL information contained herein is TRUE and CORRECT and that I/we understand that any misstatement of fact is a misdemeanor of the third degree punishable by a |
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fine up to $2,500 and/or imprisonment up to 1 year (18 Pa.C.S. Section 4904[b]). |
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_____________________________________________________ |
_______________________________________________ |
________________________________ |
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Printed Name of Registration Plate Owner |
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Owner Signature |
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Date |
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_____________________________________________________ |
_______________________________________________ |
________________________________ |
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Printed Name of Registration Plate Co-Owner |
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Co-Owner Signature |
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Date |
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NOTE TO VEHICLE OWNER: You must retain a copy of this receipt in order to obtain a replacement registration plate from an authorized agent. |
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FOR DEPARTMENT USE ONLY |
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Agent/Messenger No. |
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Date Received |
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Year |
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