Form PS2010B "Self Certification for Volunteer Ambulance Attendant Plates" - Minnesota

What Is Form PS2010B?

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 August 1, 2014;
  • 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 PS2010B 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 PS2010B "Self Certification for Volunteer Ambulance Attendant Plates" - Minnesota

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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
445 Minnesota Street, St. Paul, MN 55101-5164
Phone: (651) 297-3166 TTY: (651) 282-6555
Web: dvs.dps.mn.gov
SELF C ERTI FICATI ON FO R VO LUNTEER AM BUL AN C E A T TEN D A N T P L AT E S
Instructions: Complete the Application for Special Plates (PS2010) and this Self-Certification for Volunteer Ambulance Attendant Plates form
(PS2010B), an addendum to the Application for Special Plates.
I certify that I am an active member of the fire department or organization for volunteer ambulance attendants (as defined in Minn. Stat. 144e
01, Subd. 15) identified below;
Subd. 15.Volunteer ambulance attendant.
"Volunteer ambulance attendant" means a person who provides emergency medical services for a Minnesota licensed ambulance
service without the expectation of remuneration and who does not depend in any way upon the provision of these services for the
person's livelihood. An individual may be considered a volunteer ambulance attendant even though the individual receives an hourly
stipend for each hour of actual service provided, except for hours on standby alert, or other nominal fee, and even though the hourly
stipend or other nominal fee is regarded as taxable income for purposes of state or federal law, provided that the hourly stipend and
other nominal fees do not exceed $6,000 annually.
I will immediately notify the department of Public Safety upon the termination of my membership in this department or organization.
Department/Origin:
Date:
Signature:
Submit completed form to:
Minnesota Department of Public Safety
Driver and Vehicle Services Division
Special Plates Unit
445 Minnesota St. Ste. 164
St. Paul, MN 55101
PS2010B (08/14)
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
445 Minnesota Street, St. Paul, MN 55101-5164
Phone: (651) 297-3166 TTY: (651) 282-6555
Web: dvs.dps.mn.gov
SELF C ERTI FICATI ON FO R VO LUNTEER AM BUL AN C E A T TEN D A N T P L AT E S
Instructions: Complete the Application for Special Plates (PS2010) and this Self-Certification for Volunteer Ambulance Attendant Plates form
(PS2010B), an addendum to the Application for Special Plates.
I certify that I am an active member of the fire department or organization for volunteer ambulance attendants (as defined in Minn. Stat. 144e
01, Subd. 15) identified below;
Subd. 15.Volunteer ambulance attendant.
"Volunteer ambulance attendant" means a person who provides emergency medical services for a Minnesota licensed ambulance
service without the expectation of remuneration and who does not depend in any way upon the provision of these services for the
person's livelihood. An individual may be considered a volunteer ambulance attendant even though the individual receives an hourly
stipend for each hour of actual service provided, except for hours on standby alert, or other nominal fee, and even though the hourly
stipend or other nominal fee is regarded as taxable income for purposes of state or federal law, provided that the hourly stipend and
other nominal fees do not exceed $6,000 annually.
I will immediately notify the department of Public Safety upon the termination of my membership in this department or organization.
Department/Origin:
Date:
Signature:
Submit completed form to:
Minnesota Department of Public Safety
Driver and Vehicle Services Division
Special Plates Unit
445 Minnesota St. Ste. 164
St. Paul, MN 55101
PS2010B (08/14)