Form Sp79 - Affidavit For Exempt License Plate Application
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1555 WRIGHT WAY
CARSON CITY, NV 89711-0700
Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas Area (702) 486-4DMV (4368)
Rural Nevada or Out of State (877) 368-7828
AFFIDAVIT FOR EXEMPT LICENSE PLATE APPLICATION
to provide services to Elderly and/or Persons with Disabilities
§
NRS 371.100, 482.268, 482.368, and 26 U.S.C.
527
I declare that ______________________________________________________________ receives funds from the State
Name of Authorized Organization
of Nevada or Federal government to provide services to the elderly or person(s) with disabilities. This vehicle is used
solely for the transportation of, or to furnish services to, the elderly or person(s) with disabilities. I understand that if this
grant expires or otherwise discontinues, the license plates must be surrendered to the Department of Motor Vehicles
immediately. I understand an annual review will be conducted to ensure the organization continues to qualify to use the
exempt license plates.
FEES:
Exempt license plate: $6.00 plus a $.50 per license plate Prison Industry Fee ($1.00 for 2 plates)
Duplicate plate: $6.00.
For Official Use Only Decal: $5.00, requesting _________ decals (number of decals)
•
Proof of ownership documents must be provided at the time of registration. If the ownership documents are not
in the name of the organization, $29.25 title fee is due to change the title in addition to the $7.00 license fee.
•
Copies of the grant award are required at the time this application is submitted to the Department. The grant
period start date __________________________ and the end date _______________________.
•
Current evidence of insurance must accompany this application.
•
A passing emission test issued within 90 days of submitting this application is required in Clark and Washoe
counties.
•
A Technology fee has been associated to each transaction.
If the application is not completed in full it will be returned to the applicant.
EX
Requesting:
Initial Issue or
Duplicate Plate
_____________________
Vehicle is a:
Passenger Vehicle, Truck, or a Large Trailer or
Motorcycle or a Small Trailer
Name of Authorized
Organization
ID # or FEIN
Physical Address
Address
City
State
Zip Code
Mailing Address
Address
City
State
Zip Code
Daytime Telephone No.
(_______) - _________________
Fax No.
(_______) - ________________
Vehicle Identification Number
County Vehicle Based In
Year
Make
Type
Cylinders
GVWR Rating
Model
Fuel Type
Axles
I, being the person authorized to apply for this registration, declare under penalty of perjury that the foregoing is true and correct.
State of Nevada
County of __________________
Signed and sworn to before me on ________________
Date
______________________________________
By
Printed Name of Authorized Agent
_________________________________________
_______________________________________
Signature of Authorized Agent
Signature of Notary or Authorized DMV Representative
SP79 (07-01-15)
Signatures must be originals. Photocopies are not acceptable.
Changes may not be made to this form once it is signed and witnessed.
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