Form VR-059 "Application for License Plates for Facilities" - Maryland

What Is Form VR-059?

This is a legal form that was released by the Maryland Department of Transportation - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2012;
  • The latest edition provided by the Maryland Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form VR-059 by clicking the link below or browse more documents and templates provided by the Maryland Department of Transportation.

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Download Form VR-059 "Application for License Plates for Facilities" - Maryland

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Motor Vehicle Administration
VR-059 (02/12)
6601 Ritchie Highway, N.E.
Glen Burnie, Maryland 21062
Application for License Plates for Facilities
Please read instructions on back carefully before completing form
A. Facility Information
Name of Facility:
Soundex #:
Street Address:
FEIN No.:
City:
County:
State:
Zip Code:
B. Leasing Company Information (if vehicle is leased)
Name of Owner:
Street Address:
City:
County:
State:
Zip Code:
C. Vehicle Information
Vehicle Identification Number (VIN):
Year:
Make:
Model:
Body Style:
Class:
Lift Equipment
Present Tag Number:
Present Sticker Number:
Title Number:
(check here)
D. Certification Statement - Owner, Officer of Corporation, Member of LLC, or Partner in Partnership
Certification Statement: I, the undersigned applicant for these special tags, hereby certify, under the penalties prescribed in
Maryland Vehicle law, that the vehicle described above is used exclusively for the transportation of individuals with disabilities and
that if the vehicle for which these plates are issued ceases to be operated for or by the above named Facility, the plates must be
returned to the Motor Vehicle Administration immediately.
Signature of Vehicle Owner:
Telephone No.:
Date:
Signature of Facility Representative:
Telephone No.:
Date:
Do not write below this line
MVA Use Only
Tags Issued:
For more information, please call: 1-800-950-1MVA (1682) (to speak with a customer service representative),
From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov
Motor Vehicle Administration
VR-059 (02/12)
6601 Ritchie Highway, N.E.
Glen Burnie, Maryland 21062
Application for License Plates for Facilities
Please read instructions on back carefully before completing form
A. Facility Information
Name of Facility:
Soundex #:
Street Address:
FEIN No.:
City:
County:
State:
Zip Code:
B. Leasing Company Information (if vehicle is leased)
Name of Owner:
Street Address:
City:
County:
State:
Zip Code:
C. Vehicle Information
Vehicle Identification Number (VIN):
Year:
Make:
Model:
Body Style:
Class:
Lift Equipment
Present Tag Number:
Present Sticker Number:
Title Number:
(check here)
D. Certification Statement - Owner, Officer of Corporation, Member of LLC, or Partner in Partnership
Certification Statement: I, the undersigned applicant for these special tags, hereby certify, under the penalties prescribed in
Maryland Vehicle law, that the vehicle described above is used exclusively for the transportation of individuals with disabilities and
that if the vehicle for which these plates are issued ceases to be operated for or by the above named Facility, the plates must be
returned to the Motor Vehicle Administration immediately.
Signature of Vehicle Owner:
Telephone No.:
Date:
Signature of Facility Representative:
Telephone No.:
Date:
Do not write below this line
MVA Use Only
Tags Issued:
For more information, please call: 1-800-950-1MVA (1682) (to speak with a customer service representative),
From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov
Instructions
Application for License Plates for Facilities
Form Purpose:
This form is used by facilities with a vehicle that is used exclusively to transport individuals with disabilities.
A facility is defined as a nursing home, health care facility, adult day care facility, retirement home, or other facility that
regularly provides transportation for individuals with disabilities.
Disability license plates issued to a facility must be used exclusively for the transportation of individuals with disabili-
ties and if the vehicle, for which these plates are issued ceases to be operated for or by the facility, the plates must be
returned to the Motor Vehicle Administration.
Fee Information:
The request for a disability plate requires the assessment of a substitute/replacement tag fee. Please submit your
completed application along with the appropriate $20.00 fee. If requesting a disability plate and it is time to renew
your vehicle registration, the registration renewal fee is also required. The registration fee will vary by the type and use
of the vehicle.
Form Completion Instructions:
Section A —Facility Information
Enter the information requested about the facility requesting plates.
Section B—Leasing Company Information (if vehicle is leased)
Enter the vehicle’s owner’s name (and co-owner, if any) and address. Include the business name and business
telephone number.
Section C—Vehicle Information
Enter the information requested about the vehicle.
Section D—Certification Statement - Owner, Officer of Corporation, Member of LLC, or Partner in Partnership
Review the Certification Statement and sign where indicated.
Only vehicles titled in a company name qualify for Facility Plates.
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