Form VSD684 "Illinois Hospice License Plates Request Form" - Illinois

Form VSD684 is a Illinois Secretary of State form also known as the "Illinois Hospice License Plates Request Form". The latest edition of the form was released in November 1, 2016 and is available for digital filing.

Download a PDF version of the Form VSD684 down below or find it on Illinois Secretary of State Forms website.

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Download Form VSD684 "Illinois Hospice License Plates Request Form" - Illinois

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Secretary of State
Illinois Hospice License Plates
Request Form
Secretary of State
Vehicle Services Department
C RE
License plates registration application forms
Special Plates Division
may be obtained in person at most Secretary of
501 S. Second St., Rm. 520
State facilities, by mail, by visiting
www.cyberdriveillinois.com or by calling
Springfield, IL 62756
800-252-8980
217-785-5215
www.cyberdriveillinois.com
Illinois Hospice License Plates allow Illinois residents to contribute to the Illinois Hospice Fund administered by the
Illinois Department of Public Health for the distribution of grants for hospice service.
Illinois Hospice License Plates are multi-year and may be displayed on passenger vehicles, B-trucks and vans weighing
8,000 pounds or less.
To purchase Illinois Hospice License Plates, please submit this request form along with your license plates registration
or renewal application and the following applicable fees to the address above.
Random-Number Illinois Hospice License Plates
Newly acquired vehicle/first-time issuance – $221 ($95 title fee, $101 registration fee, $25 special plate fee).
Currently titled vehicle/first-time issuance – $126 ($101 registration fee, $25 special plate fee).
Current plates expire within 90 days – $155 ($101 registration fee, $29 replacement fee, $25 special plate
fee).
Current plates do not expire within 90 days – $54 ($29 replacement fee, $25 special plate fee).
Annual renewal – $126 ($101 registration fee, $25 special plate fee).
Vanity Illinois Hospice License Plates
Newly acquired vehicle/first-time issuance – $315 ($95 title fee, $101 registration fee, $25 special plate fee,
$94 vanity fee).
Currently titled vehicle/first-time issuance – $220 ($101 registration fee, $25 special plate fee, $94 vanity fee)
Current plates expire within 90 days – $249 ($101 registration fee, $29 replacement fee, $25 special plate
fee, $94 vanity fee).
Current plates do not expire within 90 days – $148 ($29 replacement fee, $25 special plate fee, $94 vanity
fee).
Annual renewal – $139 ($101 registration fee, $25 special plate fee, $13 vanity fee).
Personalized Illinois Hospice License Plates
Newly acquired vehicle/first-time issuance – $268 ($95 title fee, $101 registration fee, $25 special
plate fee, $47 personalized fee).
Currently titled vehicle/first-time issuance – $173 ($101 registration fee, $25 special plate fee,
$47 personalized fee).
Current plates expire within 90 days – $202 ($101 registration fee, $29 replacement fee, $25
special plate fee, $47 personalized fee).
Current plates do not expire within 90 days – $101 ($29 replacement fee, $25 special plate fee,
$47 personalized fee).
Annual renewal – $133 ($101 registration fee, $25 special plate fee, $7 personalized fee).
Printed by authority of the State of Illinois. November 2016 —1— VSD-684.4
Secretary of State
Illinois Hospice License Plates
Request Form
Secretary of State
Vehicle Services Department
C RE
License plates registration application forms
Special Plates Division
may be obtained in person at most Secretary of
501 S. Second St., Rm. 520
State facilities, by mail, by visiting
www.cyberdriveillinois.com or by calling
Springfield, IL 62756
800-252-8980
217-785-5215
www.cyberdriveillinois.com
Illinois Hospice License Plates allow Illinois residents to contribute to the Illinois Hospice Fund administered by the
Illinois Department of Public Health for the distribution of grants for hospice service.
Illinois Hospice License Plates are multi-year and may be displayed on passenger vehicles, B-trucks and vans weighing
8,000 pounds or less.
To purchase Illinois Hospice License Plates, please submit this request form along with your license plates registration
or renewal application and the following applicable fees to the address above.
Random-Number Illinois Hospice License Plates
Newly acquired vehicle/first-time issuance – $221 ($95 title fee, $101 registration fee, $25 special plate fee).
Currently titled vehicle/first-time issuance – $126 ($101 registration fee, $25 special plate fee).
Current plates expire within 90 days – $155 ($101 registration fee, $29 replacement fee, $25 special plate
fee).
Current plates do not expire within 90 days – $54 ($29 replacement fee, $25 special plate fee).
Annual renewal – $126 ($101 registration fee, $25 special plate fee).
Vanity Illinois Hospice License Plates
Newly acquired vehicle/first-time issuance – $315 ($95 title fee, $101 registration fee, $25 special plate fee,
$94 vanity fee).
Currently titled vehicle/first-time issuance – $220 ($101 registration fee, $25 special plate fee, $94 vanity fee)
Current plates expire within 90 days – $249 ($101 registration fee, $29 replacement fee, $25 special plate
fee, $94 vanity fee).
Current plates do not expire within 90 days – $148 ($29 replacement fee, $25 special plate fee, $94 vanity
fee).
Annual renewal – $139 ($101 registration fee, $25 special plate fee, $13 vanity fee).
Personalized Illinois Hospice License Plates
Newly acquired vehicle/first-time issuance – $268 ($95 title fee, $101 registration fee, $25 special
plate fee, $47 personalized fee).
Currently titled vehicle/first-time issuance – $173 ($101 registration fee, $25 special plate fee,
$47 personalized fee).
Current plates expire within 90 days – $202 ($101 registration fee, $29 replacement fee, $25
special plate fee, $47 personalized fee).
Current plates do not expire within 90 days – $101 ($29 replacement fee, $25 special plate fee,
$47 personalized fee).
Annual renewal – $133 ($101 registration fee, $25 special plate fee, $7 personalized fee).
Printed by authority of the State of Illinois. November 2016 —1— VSD-684.4
Print
Reset
Random-Number Illinois Hospice License Plates Request Form
Vehicle Owner’s Name ________________________________________________________________
Address ___________________________________________________________________________
City/State/ZIP ______________________________________________________________________
Telephone Number___________________________________________________________________
Current License Plate Number_____________________________________Expiration Date _________
Type of Plate
J Passenger
J Truck
Vanity & Personalized Illinois Hospice License Plates Request Form
Vehicle Owner’s Name
Address
OFFICE USE ONLY
City
State
ZIP
Daytime Telephone Number (8 a.m. - 4:30 p.m.)
Current License Plate #
Expiration Date
1st choice
2nd choice
3rd choice
If your exact 1st, 2nd and 3rd choices are not available, would you like the next plate number available in that series?
J Yes
J No
If you want a space between letters, please indicate with a slash mark. An automatic space is required between letters and numbers.
Illinois Hospice Reserves Plates
Illinois Hospice Reserves Plates
E
examples
A B C D
A B C
Numbers 1-999
1 or 2 letters plus 1-99
or
or
(Note: 4-letter Illinois Hospice plates cannot have a space. Spacing will vary with the type of plate requested.
1, 2, 3, 4 or 5 letters
3 letters plus 1-9
Proper completion of this form is the customer’s responsibility.)
Vanity/Personalized License Plates
• No refund or adjustment will be made for a change of choice or spacing after a plate has been ordered or if the request
form is incorrectly completed.
• The Secretary of State’s office is authorized to recall a plate determined to be obscene or offensive.
• All request forms should indicate whether you want the Secretary of State to assign one of your choices with the next
available number if your exact request is unavailable.
• If you wish to submit more than three requests, attach additional selections to the request form.
DO NOT
• Intermix letters and numbers.
• Use a space between numbers.
• Use lowercase letters.
• Use characters, symbols, foreign words or symbols of punctuation, such as dashes or periods.
• Select obscene or offensive combinations.
First-Time Registrations
• Money must accompany request forms on all first-time registrations.
• A leased vehicle is eligible for vanity or personalized plates.
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