Form PS2013 "' gold Star Family Plate Application" - Minnesota

What Is Form PS2013?

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

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the Minnesota Department of Public Safety;
  • 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 PS2013 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS2013 "' gold Star Family Plate Application" - Minnesota

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OFFICE USE ONLY
Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
Assigned Plate No.
Assigned Sticker No.
Go l d S ta r L ic e nse P l at e App lic ati on
Weight Sticker No.
• Print and mail this completed application to Driver and Vehicle Services, 445 Minnesota Street,
PAID STAMP
St. Paul, Minnesota 55101-5164. It may also be submitted at Deputy Registrar offices statewide.
• If you have questions or need additional information, please contact DVS at (651) 297-3166.
• Gold Star Family plates are available to the parent, spouse, sibling or child of a person who has died while
honorably serving in active service. Funding is provided by the Minnesota Department of Veteran Affairs
through Support Our Troops license plate contributions.
• Applicant must provide DD1300 "Report of Casualty," DD2064 "Certificate of Death," or have
certification of eligibility from the Commissioner of Veteran Affairs.
• Except for certain uses permitted by federal and state laws, personal information contained in your
application may not be disclosed to anyone without your express consent. You may expressly
consent to the disclosure of your personal information by writing to the address above.
Gold Star Family License Plate
Type or Print Full Name of person who has died while honorably serving in active service
Spouse
Parent
Sibling
Child
Darken your relation to the above-named person:
Describe below the vehicle on which the plates will be used:
Year/Make
Vehicle Identification Number
Current Plate Number
Expiration Date (MM/YY)
Print Name of Applicant/Owner
Driver's Date of Birth
(mm/dd/yy)
Driver's License Number (omit dashes)
Print Name of Additional Owner
Driver's Date of Birth
(mm/dd/yy)
Driver's License Number (omit dashes)
Address
City/State/Zip
X
Signature
If special plates must be replaced, darken the reason below.
$
REGISTRATION TAX
Never Received
Lost
$None
PLATE FEE
Stolen
Destroyed
TECH SURCHARGE (Due only with
$
renewal)
Damaged
Defective
$10
FILING FEE
TOTAL DUE
$
PS2013-04 (07/15)
OFFICE USE ONLY
Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
Assigned Plate No.
Assigned Sticker No.
Go l d S ta r L ic e nse P l at e App lic ati on
Weight Sticker No.
• Print and mail this completed application to Driver and Vehicle Services, 445 Minnesota Street,
PAID STAMP
St. Paul, Minnesota 55101-5164. It may also be submitted at Deputy Registrar offices statewide.
• If you have questions or need additional information, please contact DVS at (651) 297-3166.
• Gold Star Family plates are available to the parent, spouse, sibling or child of a person who has died while
honorably serving in active service. Funding is provided by the Minnesota Department of Veteran Affairs
through Support Our Troops license plate contributions.
• Applicant must provide DD1300 "Report of Casualty," DD2064 "Certificate of Death," or have
certification of eligibility from the Commissioner of Veteran Affairs.
• Except for certain uses permitted by federal and state laws, personal information contained in your
application may not be disclosed to anyone without your express consent. You may expressly
consent to the disclosure of your personal information by writing to the address above.
Gold Star Family License Plate
Type or Print Full Name of person who has died while honorably serving in active service
Spouse
Parent
Sibling
Child
Darken your relation to the above-named person:
Describe below the vehicle on which the plates will be used:
Year/Make
Vehicle Identification Number
Current Plate Number
Expiration Date (MM/YY)
Print Name of Applicant/Owner
Driver's Date of Birth
(mm/dd/yy)
Driver's License Number (omit dashes)
Print Name of Additional Owner
Driver's Date of Birth
(mm/dd/yy)
Driver's License Number (omit dashes)
Address
City/State/Zip
X
Signature
If special plates must be replaced, darken the reason below.
$
REGISTRATION TAX
Never Received
Lost
$None
PLATE FEE
Stolen
Destroyed
TECH SURCHARGE (Due only with
$
renewal)
Damaged
Defective
$10
FILING FEE
TOTAL DUE
$
PS2013-04 (07/15)