APPLICATION FOR SPECIAL INTEREST LICENSE PLATE DECAL
This application is provided in accordance with Ark. Code Ann. § 27-24-1404. Applicants may apply for a special
interest license plate decal beginning on July 1 and ending on November 1 each year. A proposed design for the special
license plate decal must accompany this application. The special license plate decal will be placed on a standard issue
license plate across the bottom of the plate in lieu of the legend “The Natural State”. A minimum of 300 signatures or
three thousand dollars ($3,000), or a combination thereof, is required before special interest plates will be ordered or
issued. Fees and/or signatures will be due upon notification by the department of approval of license plate decal design.
DO NOT SEND FEES WITH THIS APPLICATION.
The organization may request to establish a fund raising fee not to exceed $25.00.
Fund raising fee to be established
Yes
No
If a fund raising fee is to be established, enter amount not to exceed $25.00.
Amount
The organization’s financial plan for use of the proceeds from the special license plate must be provided in the appropriate
section below and the affidavit must be signed by an official of the organization.
Both front and back of this application must be completed.
Name and Address of Organization:
Financial Plan
AFFIDAVIT
I
hereby swear and affirm that the
Printed Name of Authorized Official of Organization
proceeds from the special license plate for the organization named herein will be used in accordance with the financial
plan above.
Signature: _______________________________________________ Date: _____________________________
This application may be submitted to either of the following addresses:
In Person:
Office of Motor Vehicle
By Mail: Department of Finance and Administration
Ragland Building, Room 2041
Office of Motor Vehicle, Room 2041
th
1900 West 7
Street
P.O. Box 1272
Little Rock, AR 72201
Little Rock, AR 72203
See the back of this application for further information.
APPLICATION FOR SPECIAL INTEREST LICENSE PLATE DECAL
This application is provided in accordance with Ark. Code Ann. § 27-24-1404. Applicants may apply for a special
interest license plate decal beginning on July 1 and ending on November 1 each year. A proposed design for the special
license plate decal must accompany this application. The special license plate decal will be placed on a standard issue
license plate across the bottom of the plate in lieu of the legend “The Natural State”. A minimum of 300 signatures or
three thousand dollars ($3,000), or a combination thereof, is required before special interest plates will be ordered or
issued. Fees and/or signatures will be due upon notification by the department of approval of license plate decal design.
DO NOT SEND FEES WITH THIS APPLICATION.
The organization may request to establish a fund raising fee not to exceed $25.00.
Fund raising fee to be established
Yes
No
If a fund raising fee is to be established, enter amount not to exceed $25.00.
Amount
The organization’s financial plan for use of the proceeds from the special license plate must be provided in the appropriate
section below and the affidavit must be signed by an official of the organization.
Both front and back of this application must be completed.
Name and Address of Organization:
Financial Plan
AFFIDAVIT
I
hereby swear and affirm that the
Printed Name of Authorized Official of Organization
proceeds from the special license plate for the organization named herein will be used in accordance with the financial
plan above.
Signature: _______________________________________________ Date: _____________________________
This application may be submitted to either of the following addresses:
In Person:
Office of Motor Vehicle
By Mail: Department of Finance and Administration
Ragland Building, Room 2041
Office of Motor Vehicle, Room 2041
th
1900 West 7
Street
P.O. Box 1272
Little Rock, AR 72201
Little Rock, AR 72203
See the back of this application for further information.
SPECIAL LICENSE PLATE DECAL PLACEMENT AND DIMENSIONS
The special license plate decal will be placed on a standard issue license plate across the bottom of the plate in lieu of the
legend “The Natural State”.
The dimensions of the special license plate decal must be three fourths (3/4) inch high and no more than six and one half
(6½) inches long.
REQUIREMENTS OF THE ORGANIZATION
An organization’s application for a special interest license plate decal must establish the organization’s compliance with
the conditions below. Each box below must be checked to establish compliance.
The organization is a state agency or a nonprofit organization that has been approved for tax exempt status under
Section 501(c)(3) of the Internal Revenue Code as in effect on January 1, 2005. A letter from the Internal
Revenue Service to the organization establishing their tax exempt status must accompany this application.
The organization is based, headquartered, or has a chapter in Arkansas;
The purpose of the organization is for social, civic, entertainment, or other purposes;
The name of the organization is not the name of a special product or a brand name;
The name of the organization is not the name of a trademark, or if so, the entity with control of the trademark has
provided written authorization for its use.
The organization is not a political party;
The organization was not created primarily to promote a specific political belief; and
The organization shall not have as its primary purpose the promotion of any specific religion, faith, or anti-
religion.
All special plates are subject to final approval by the Department of Finance and Administration.
NAME AND ADDRESS OF PERSON TO CONTACT BY DEPARTMENT
PHONE NUMBER
E-MAIL ADDRESS IF ANY
ANNUAL REPORT REQUIRED
Under Arkansas Code §27-24-1407, an organization that is the sponsor of a special interest license plate that bears a decal
under this subchapter shall prepare and submit an annual accounting report to the Director of the of the Department of
Finance and Administration by December 1 of each calendar year. The report shall include an accounting of the revenues
and expenditures associated with the fund raising fees charged for the special license plate that bears a decal. This report
may be submitted to the addresses on the front of the application.
If the special interest organization fails to comply with this section, the Director of the Department of Finance and
Administration may suspend issuance of a special license plate that bears a decal and suspend payment of the fund raising
fee to the special interest organization.
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