Form PS2041 "Application for Special Registration Plates" - Minnesota

What Is Form PS2041?

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 December 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 PS2041 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 PS2041 "Application for Special Registration Plates" - Minnesota

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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES - LICENSE PLATE IMPOUND UNIT
445 Minnesota Street, Suite 166
Saint Paul, MN 55101-5166
NEW PLATE # ISSUED
Phone: (651) 297-5034 FAX: (651) 797-1810 TTY: (651) 282-6555
Web: dvs.dps.mn.gov
App li ca tio n f or S pe c ia l Re gi st ration P la te s
NEW YEAR VALIDATION # ISSUED
PLEASE READ INSTRUCTIONS ON BACK BEFORE COMPLETING THIS FORM.
CURRENT PLATE #
VEHICLE IDENTIFICATION NUMBER
NEW WEIGHT STICKER # ISSUED
MODEL YEAR
PLATE YEAR
MAKE
TYPE
CURRENT EXP. DATE
MONTH
/
YEAR
DEPUTY STAMP
NAME OF OWNER(S) (LAST, FIRST AND MIDDLE)
DRIVER'S LICENSE NUMBER
PRINT PERMANENT ADDRESS: STREET
CITY
COUNTY
STATE
ZIP CODE
MAILING ADDRESS: STREET
CITY
COUNTY
STATE
ZIP CODE
(if different than above)
FEES DUE
Name of Driver at Incident
(at time of incident)
SPECIAL PLATE FEE
Incident Date (mm/dd/yyyy)
Date of Birth (mm/dd/yyyy)
REGISTRATION TAX
INSURANCE: MN Statute 169.78 Subd. 4 Every owner, when applying for vehicle registration, re-registration, or transfer
of ownership, must provide information showing that the vehicle is covered by an insurance policy.
FILING FEE
Required information consists of:
Company Name:
TOTAL DUE
Policy Number:
Policy Expiration Date: (mm/dd/yyyy)
If owner is valid or has a limited license they may use their information as qualified driver (a 7-day temp permit does not qualify)
If owner is not valid; a qualified driver must fill in the information and sign below.
QUALIFIED DRIVER STATEMENT
I am requesting authorization to receive special registration plates for the above-described vehicle. Only a driver with a valid or limited license may use the
above-described vehicle with the special registration plates.
QUALIFIED DRIVER'S FULL NAME
DATE OF BIRTH
DRIVER'S LICENSE NUMBER
I have a valid or limited driver’s license (Note: A 7-day temp. license or learners permit is not acceptable), and I know that a person may not drive, operate or
be in physical control of a vehicle without a valid or limited driver’s license.
X
Qualified licensed driver must sign here:
Vehicle Owner:
I request authorization for special registration plates for the above-described vehicle. I do certify all of the declarations are true and correct.
I understand that only a driver with a valid or limited license may use the above-described vehicle with the special registration plates.
I know that no person may drive, operate or be in physical control of a vehicle without a valid driver’s license.
I understand that Special Registration plates must be displayed for a minimum of one year from the date of qualifying incident and where the
violator is also an owner, co-owner, or lessee of the vehicle; plates must be displayed until their driving privileges are fully valid, whichever
period of time is longer.
Date
X
Vehicle Owner must sign here
IMPORTANT NOTICE: PLEASE READ
The month and year stickers you are replacing must match those originally on this vehicle. The application for plates must be completed by the
registered owner(s), and any remaining plates and/or stickers must be surrendered.
All data collected on a motor vehicle application is required by law. This data is used to identify your motor vehicle. Failure to provide required data may result
in denial of the transfer of ownership, registration of this vehicle, or other requested action.
-OVER-
PS2041-8 Rev. 12/15
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES - LICENSE PLATE IMPOUND UNIT
445 Minnesota Street, Suite 166
Saint Paul, MN 55101-5166
NEW PLATE # ISSUED
Phone: (651) 297-5034 FAX: (651) 797-1810 TTY: (651) 282-6555
Web: dvs.dps.mn.gov
App li ca tio n f or S pe c ia l Re gi st ration P la te s
NEW YEAR VALIDATION # ISSUED
PLEASE READ INSTRUCTIONS ON BACK BEFORE COMPLETING THIS FORM.
CURRENT PLATE #
VEHICLE IDENTIFICATION NUMBER
NEW WEIGHT STICKER # ISSUED
MODEL YEAR
PLATE YEAR
MAKE
TYPE
CURRENT EXP. DATE
MONTH
/
YEAR
DEPUTY STAMP
NAME OF OWNER(S) (LAST, FIRST AND MIDDLE)
DRIVER'S LICENSE NUMBER
PRINT PERMANENT ADDRESS: STREET
CITY
COUNTY
STATE
ZIP CODE
MAILING ADDRESS: STREET
CITY
COUNTY
STATE
ZIP CODE
(if different than above)
FEES DUE
Name of Driver at Incident
(at time of incident)
SPECIAL PLATE FEE
Incident Date (mm/dd/yyyy)
Date of Birth (mm/dd/yyyy)
REGISTRATION TAX
INSURANCE: MN Statute 169.78 Subd. 4 Every owner, when applying for vehicle registration, re-registration, or transfer
of ownership, must provide information showing that the vehicle is covered by an insurance policy.
FILING FEE
Required information consists of:
Company Name:
TOTAL DUE
Policy Number:
Policy Expiration Date: (mm/dd/yyyy)
If owner is valid or has a limited license they may use their information as qualified driver (a 7-day temp permit does not qualify)
If owner is not valid; a qualified driver must fill in the information and sign below.
QUALIFIED DRIVER STATEMENT
I am requesting authorization to receive special registration plates for the above-described vehicle. Only a driver with a valid or limited license may use the
above-described vehicle with the special registration plates.
QUALIFIED DRIVER'S FULL NAME
DATE OF BIRTH
DRIVER'S LICENSE NUMBER
I have a valid or limited driver’s license (Note: A 7-day temp. license or learners permit is not acceptable), and I know that a person may not drive, operate or
be in physical control of a vehicle without a valid or limited driver’s license.
X
Qualified licensed driver must sign here:
Vehicle Owner:
I request authorization for special registration plates for the above-described vehicle. I do certify all of the declarations are true and correct.
I understand that only a driver with a valid or limited license may use the above-described vehicle with the special registration plates.
I know that no person may drive, operate or be in physical control of a vehicle without a valid driver’s license.
I understand that Special Registration plates must be displayed for a minimum of one year from the date of qualifying incident and where the
violator is also an owner, co-owner, or lessee of the vehicle; plates must be displayed until their driving privileges are fully valid, whichever
period of time is longer.
Date
X
Vehicle Owner must sign here
IMPORTANT NOTICE: PLEASE READ
The month and year stickers you are replacing must match those originally on this vehicle. The application for plates must be completed by the
registered owner(s), and any remaining plates and/or stickers must be surrendered.
All data collected on a motor vehicle application is required by law. This data is used to identify your motor vehicle. Failure to provide required data may result
in denial of the transfer of ownership, registration of this vehicle, or other requested action.
-OVER-
PS2041-8 Rev. 12/15
Application for Special Registration Plates
INFORMATION
LICENSE PLATE IMPOUNDMENT
REQUEST FOR AN ADMINISTRATIVE REVIEW
You have the right to request the department to conduct an administrative review of a license plate impoundment order. You may request the
administrative review anytime during the impoundment period. The request must be in writing or on the form prescribed by the department
(PS31125).
The department will only rescind a license plate impoundment order if:
• The violator is not an owner or co-owner of the vehicle.
• The owner of the vehicle was not a passenger at the time of the incident, and
• The violator had a valid drivers license at the time of the incident or,
• The owner filed a report with law enforcement before the incident stating that the vehicle had been taken from the owner’s possession
or was being used without permission. You must submit a copy of the police report with your request.
PETITION FOR JUDICIAL REVIEW
You have the right to petition the court for a judicial review of the license plate impoundment order in the county in which the incident occurred.
The petition must be made to the court within 30-days of the Notice of License Plate Impoundment.
SALE OF VEHICLE SUBJECT TO IMPOUNDMENT ORDER
A registered owner may not sell a vehicle while the license plates are impounded or while special registration plates are displayed on the
vehicle unless;
• The sale is for valid consideration (fair market value).
”Gifts” will not be approved. A low purchase price must be justified with repair estimates.
• The purchaser is not a household member (Significant Relation).
• The purchaser is not a family member.
“Significant Relation” is defined in Minnesota Statute 169A.60 as “any person with whom the actor (violator or owner) regularly associates and
communicates with outside of a workplace setting”
ELIGIBILITY FOR SPECIAL REGISTRATION PLATES
Special series license plates may be issued to a vehicle owner if they have a valid or limited license. You may also apply for special registration
plates if a qualified driver is willing to operate the vehicle and has a valid or limited driver’s license.
(A 7-day temporary license does not qualify) Both vehicle owner and qualified driver must sign for the special series license plates.
ACQUIRING A NEW OR USED VEHICLE DURING THE IMPOUNDMENT PERIOD
Pursuant to Minnesota Statutes, section 169A.60, “if during the effective period of the plate impound the violator applies for registration plates
for any vehicle, the commissioner shall not issue plates unless the violator qualifies for special registration plates. If the violator acquires a
new or used vehicle during the plate impoundment period, (as sole or joint owner or lessee) the newly acquired vehicle may only display special
registration plates providing all qualifications are met.”
REINSTATEMENT OF REGULAR LICENSE PLATES AND REGISTRATION
Violator owners: The plate impound period is in effect on all vehicles registered, owned, co-owned or leased by the violator for at least one
year from the date of qualifying incident and during the time the violator’s drivers license status is canceled/revoked whichever period of time is
longer. After one year you may qualify for regular license plates once your driver’s license is reinstated (a limited license is not a
reinstatement).
Non-violator owners: The plate impound period is at least one year from the date of qualifying incident.
Pursuant to Minnesota Statutes, section 169A.60, a $50 plate reinstatement fee is due in addition to regular license plate and registration fees.
PS2041-8 Rev. 12/15
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