REQUEST FOR SUSAN G. KOMEN
BREAST CANCER EDUCATION, RESEARCH, AND AWARENESS
SPECIAL LICENSE PLATE
Please read the instructions on the back of this form and complete the information requested
below. Present the form to any of the Revenue Office locations as instructed below when
making application for the special license plate.
Name of Vehicle Owner
Address
City, State, Zip
Vehicle Year
Vehicle Make
Vehicle Model
License Number
Apply in person only at the following Revenue Office locations:
Fayetteville, Jonesboro, Pine Bluff, Texarkana, West Memphis, Harrison, Russellville, Conway,
Mountain View, Hot Springs (Airport Office), Van Buren, Monticello and El Dorado.
Apply by mail or in person at the following addresses:
By Mail
In Person
Department of Finance and Administration
Charles Ragland Taxpayer Services Center
P.O. Box 1272
Special License Unit, Room 1040
th
Special License Unit, Room 1040
1900 West 7
Street
Little Rock, AR 72203
Little Rock, Arkansas 72201
Signature
Date
REQUEST FOR SUSAN G. KOMEN
BREAST CANCER EDUCATION, RESEARCH, AND AWARENESS
SPECIAL LICENSE PLATE
Please read the instructions on the back of this form and complete the information requested
below. Present the form to any of the Revenue Office locations as instructed below when
making application for the special license plate.
Name of Vehicle Owner
Address
City, State, Zip
Vehicle Year
Vehicle Make
Vehicle Model
License Number
Apply in person only at the following Revenue Office locations:
Fayetteville, Jonesboro, Pine Bluff, Texarkana, West Memphis, Harrison, Russellville, Conway,
Mountain View, Hot Springs (Airport Office), Van Buren, Monticello and El Dorado.
Apply by mail or in person at the following addresses:
By Mail
In Person
Department of Finance and Administration
Charles Ragland Taxpayer Services Center
P.O. Box 1272
Special License Unit, Room 1040
th
Special License Unit, Room 1040
1900 West 7
Street
Little Rock, AR 72203
Little Rock, Arkansas 72201
Signature
Date
INSTRUCTIONS FOR OBTAINING THE SPECIAL LICENSE PLATE
RESTRICTIONS – Issuance is restricted to passenger cars, all ½ ton and ¾ ton trucks, and 1 ton trucks use for private transportation only. One
(1) ton trucks used for commercial purposes must be registered with a commercial license.
In addition to normal annual registration fees, there are additional fees in the amounts of twenty-five dollars ($25.00) for the Breast Cancer
Research Fund and ten dollars ($10.00) for handling and administrative costs. These fees are due annually.
See the front of this form for the Revenue Offices where these plates are available. If a special plate is lost, it may be replaced with another
special plate only in the offices listed. The special plates may be renewed in any Revenue Office, by mail, Internet, or telephone. They may be
transferred to a newly acquired vehicle in any Revenue Office.
OBTAINING A SPECIAL LICENSE PLATE FOR A VEHICLE ALREADY TITLED
AND REGISTERED TO THE APPLICANT
REQUIREMENTS – Two options are available when obtaining a special plate when the vehicle is already titled and registered in the applicant’s
name.
Option 1 – If the applicant’s existing plate is current, it may be replaced with a special plate. With this option, the special plate will keep the
same expiration date as the plate being replaced. Applicants will get the entire benefit of the full registration fee paid for the plate being replaced.
However, since the expiration date will remain the same, they will not get a full year’s benefit of the $25.00 or $10.00 special fees. When
renewing, the applicant will be required to pay both additional fees again.
Fees for obtaining the plate using option 1 are as follows:
Special design use fee for the special plate is………………………………$ 25.00
Fee for replacement of the regular plate…………………………………….
1.00
Special fee for administrative costs………………………………………… 10.00
1.39 or if in person .39 cents
Postage fee (if the transaction is done by mail)……………………………
Total Fees (if the transaction is done by mail)……………………………… 37.39 or if in person 36.39
Other requirements are:
Completed request for Susan G. Komen Breast Cancer Education, Research, and Awareness Special License Plate form.
Option 2 – The applicant may request to pay the normal full year registration fee for the vehicle and begin the special license plate with a full
year’s registration. With this option, the applicant will get full benefit of the $25.00 and $10.00 additional fees. However, no credit will be given
for the time remaining on the plate being replaced.
Fees for obtaining the plate using option 2 are as follows:
The full year registration fee normally due for the vehicle will be due. For passenger cars, this fee will either be $17.00, $25.00, or $30.00
depending on the vehicle’s unladen weight. For qualifying trucks (see restrictions) the full year fee is $21.00.
Special fee for Breast Cancer Research Fund is $25.00
Validation decal fee is $2.50
Special fee for administrative costs is $10.00
Postage fee if the transaction is done by mail is $1.39
Postage fee if the transaction is done in person in the Special License Unit is .39 cents.
Total fees depend on the normal registration fee for the vehicle and postage fees.
Other requirements are:
Completed request for Susan G. Komen Breast Cancer Education, Research, and Awareness Special License Plate form.
Proof of current liability insurance.
If the applicant’s existing license plate is expired, or will expire in the current calendar year, the following personal property
tax information is required
Proof of personal property assessment for the current year
o
Proof of personal property tax payment of taxes due by October 10 of the previous year.
o
If the applicant’s existing license plate will expire the next calendar year, proof of personal property assessment and tax payment are not
required.
OBTAINING A SPECIAL PLATE FOR A NEWLY PURCHASED VEHICLE
If obtaining a special plate is for a newly purchased vehicle, all normal documentation for title and registration is required. Applicants
should contact their local Revenue Office for assistance.
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