Form Mv-77a - Application For Farm Vehicle 2-Year Certificate Of Exemption

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MV-77A (7-17)

APPLICATION FOR FARM VEHICLE 2-YEAR

www dmv pa gov

CERTIFICATE OF EXEMPTION

For Department Use Only

SEE REVERSE SIDE FOR INSTRUCTIONS AND IMPORTANT INFORMATION

Bureau of Motor Vehicles • 1101 South Front Street • Harrisburg, PA 17104

Initial Issuance of Certificate of Exemption - Complete Sections A through D and F.

Renewal of Certificate of Exemption - Complete Sections A, C, D and F.

Replacement of Certificate Card - Complete Sections A, C, E, F or G (if applicable) without Exemption Sticker. FEE: $6

Replacement of Exemption Sticker - Complete Sections A, C, D, E, F or G (if applicable). FEE: $6

A APPLICANT(S) INFORMATION

B FARM/AGRICULTURAL BUSINESS INFORMATION

List individual, business or corporation name and Taxpayer Identification

List name and address as printed on current PA title or as listed on

accompanying application for PA title.

No. under which you as an owner/operator of a farm last filed on your

Pennsylvania or Federal Income Tax Forms. A PA Driver’s License No. may

Name(s)

be used in lieu of a Social Security No. See reverse side for a listing of

the tax forms that must be copied and attached to this application.

Name

PA DL/Photo ID#/TIN

Street Address

City

State

Zip Code

Identify the primary agricultural

commodity produced by your farm

C VEHICLE AND INSURANCE INFORMATION

Title Number

Vehicle Identification Number

Year

Make

Body Type

Registration Plate or Certificate Number

Registration Plate or Certificate Expiration Date

GVWR

Insurance Company Name

Insurance Policy Number

Policy Effective Date

Policy Expiration Date

D CERTIFICATE OF EXEMPTION TYPE INFORMATION

CHECK ONE:

Initial Application for Certificate of Exemption

Renewal of Certificate of Exemption

TYPE A - Vehicle with a gross vehicle weight rating or combination weight rating of 10,000 pounds or less. FEE: $25. NOTE: Type A vehicles do not require annual safety

inspection and may only be driven upon highways from sunrise to sunset.

TYPE B - Vehicle with a gross vehicle weight rating or combination weight rating between 10,001 and 17,000 pounds. FEE: $25. NOTE: Type B vehicles do not require

annual safety inspection and may only be driven upon highways from sunrise to sunset.

TYPE C - Vehicle with a gross vehicle weight rating or combination weight rating of 17,001 pounds or greater. FEE: $52. NOTE: Type C vehicles do not require annual

safety inspection and may only be driven upon highways from sunrise to sunset.

TYPE D - Vehicle with a gross vehicle weight rating or combination weight rating of 17,001 pounds or greater. FEE: $104. NOTE: Type D vehicles are subject to annual

safety inspection and may be driven upon highways without any time restrictions.

E IF APPLYING FOR REPLACEMENT CERTIFICATE CARD OR EXEMPTION STICKER, CHECK REASON:

Lost

Stolen

Defaced

Never Received - (If “Never Received” block is checked, SECTION G MUST BE COMPLETED.)

F APPLICANT(S) CERTIFICATION AND SIGNATURE

I/We certify under penalty of law that all information listed above is true and correct and that I/we am/are a farm owner/operator. I/We further certify that the

vehicle displaying the plate/biennial Certificate of Exemption is a farm vehicle and will be operated upon public highways as indicted on the reverse side of

this application and used exclusively for agricultural purposes and will be driven only on highways between parts of one farm owned and operated by me/us;

between such a farm and a place of business for the purposes of buying or selling agricultural commodities or supplies or for the inspection, repair or servicing

of the vehicle, and further acknowledge that I/we may lose my/our operating privilege or vehicle exemption for failure to maintain financial responsibility

(insurance) for the period of registration or exemption and attest to knowledge of all State and Federal Motor Carrier Safety laws and regulations. WARNING:

Misstatement of fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year (18 Pa.C.S., Section 4904[b]).

Applicant Signature_________________________________________________________

Date of Application____________________________

Co-Applicant Signature ______________________________________________________

Date of Application____________________________

APPLICATION FOR FREE REPLACEMENT - Complete only if applicant is entitled to a free re-issuance because original Certificate Card or

Exemption Sticker was never received in the mail and application is being made within 90 days of original issuance.

I/We hereby swear that application was made for the above and that the items as

SUBSCRIBED AND SWORN

indicated were never received in the mail.

TO BEFORE ME:

MO.

DAY