Form Mv-653em - Certification Of Eligibility For Emergency Management Plates
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1
2CERTIFICATION OF ELIGIBILITY FOR
EMERGENCY MANAGEMENT PLATES
Department of Homeland Security (DHSES) authorization is required for the issuance of Emergency Management plates.
DHSES authorization is NOT required to transfer existing Emergency Management plates.
This form is to be used by New
York State agencies and political subdivisions to certify eligibility for Emergency Management plates. A political subdivision is
defined as a subdivision of New York State that has been delegated certain official functions of state or local government, including
a government entity created by, or under the authority of, State law. A vehicle assigned Emergency Management plates must be
owned or controlled by a state agency or a political subdivision and operated by its employees, or specifically designated agents
thereof, in the course of their official duties. The vehicle must be registered in the name of the state agency or political subdivision.
PLEASE CHECK THE APPROPRIATE BOX BELOW TO INDICATE YOUR OFFICIAL GOVERNMENT STATUS:
Government Division, District or Other Government Entity:
o
o
o
o
o
o
State Agency
County
City
Town
Village
Authority
Name of NYS Agency, County, City, Town, Village, District or Authority
Department or Division
Address
Name of Department or Division Director
Business Phone
Business E-Mail Address (Optional)
DESCRIPTION OF VEHICLE(S):
o
Check this box if you are certifying multiple vehicles. Provide the vehicle information on the reverse side of this form.
o
I am transferring plate ________________________ to this vehicle.
Year
Make
Model
Vehicle ID # (VIN)
Plate Number (if currently registered)
County of Primary Use
CERTIFICATION
I certify that the above-described vehicle(s) is (are) owned or controlled by the state agency or political subdivision to which
this application for registration applies, and that the information contained herein is true and accurate. I do so in my capacity as
a duly appointed public officer or official who has been granted the authority to act on behalf of the above-named political
subdivision or state agency.
I understand that knowingly making a false statement on an application submitted to the Commissioner of Motor Vehicles is a
misdemeanor under Vehicle and Traffic Law, a misdemeanor or felony under New York State Penal Law, and may result in
criminal prosecution in addition to revocation or suspension of the registration pursuant to regulations promulgated by the
Commissioner of Motor Vehicles.
If you
Emergency Management plate applications must be signed by the highest ranking elected or appointed official.
have questions or need further information call DHSES at (518) 292-2865.
x
Signature
______________________________________________________________ Date:________________________
(Sign Your Name in Full)
Print Your Name: ______________________________________________ Title: ____________________________________
Address: ______________________________________________________________________________________________
City: _______________________________________________________________ Zip Code: __________________________
Your Business
Your Business
(
)
Phone number ______________________________
E-Mail Address (optional): ____________________________________
I authorize the issuance of Emergency Management License Plates for _____ vehicles (indicate the number of vehicles authorized).
x
Signature
________________________________________________________
Date: _______________________
Commissioner of Homeland Security and Emergency Services
o
o
Authorization Code ______________________
Code from List
Code from IOCU
x
DMV Supervisor Approval
___________________________________________
Date: _______________________
(Signature)
MV-653EM (1/18)
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