Form DPSMV1912 "Gold Star License Plate Applicant Certification" - Louisiana

What Is Form DPSMV1912?

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

Form Details:

  • Released on March 1, 2009;
  • The latest edition provided by the Louisiana Department of Public Safety & Corrections;
  • 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 DPSMV1912 by clicking the link below or browse more documents and templates provided by the Louisiana Department of Public Safety & Corrections.

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Download Form DPSMV1912 "Gold Star License Plate Applicant Certification" - Louisiana

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GOLD STAR LICENSE PLATE
APPLICANT CERTIFICATION
Immediate family members of individuals who have died in military service use this form to request a Gold Star license plate.
PLATE INFORMATION
Louisiana legislation provides that immediate family members of persons who have died in military service to their country can
apply for special Gold Star license plates by submitting a copy of the death certificate of the armed forces member who lost his
life. The license plate can be used upon personally or jointly owned private passenger cars, pickup trucks, vans, motorcycles,
and recreational vehicles registered in the name, or jointly in the name, of the member making application. Check the
applicable condition.
During World War I, World War II, or any subsequent period of armed hostilities in which the United States was engaged
before July 1, 1958, or
Anytime after June 30, 1958:
a. while engaged in an action against an enemy of the United States;
b. while engaged in military operations involving conflict with an opposing foreign force;
c. while serving with friendly forces engaged in an armed conflict in which the United States is not a belligerent
party against an opposing armed force; or
Anytime after March 28, 1973, as a result of:
a. an international terrorist attack against the United States or a foreign nation friendly to the United States,
recognized as such an attack by the U.S. Secretary of Defense; or
b. military operations while serving outside the United States, including commonwealths, territories, and
possessions of the United States, as part of a peacekeeping force.
APPLICANT INFORMATION
APPLICANT NAME
DECEASED SERVICE MEMBER NAME
APPLICANT RELATIONSHIP TO DECEASED SERVICE MEMBER (check applicable box)
Foster parents who stood in loco parentis
Brother
Widow (remarried or not)
Stepmother
Widower (remarried or not)
Stepfather
Child
Half brother
Stepchild
Sister
Mother
Mother through adoption
Adopted child
Half sister
Father
Father through adoption
CERTIFICATION
I hereby certify that the information contained in this certification is true and correct to the best of my knowledge. I
understand that it is unlawful to knowingly make a false statement and any violation may be prosecuted as a felony as
provided in Louisiana law.
APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
DPSMV 1912 (R 03/09)
GOLD STAR LICENSE PLATE
APPLICANT CERTIFICATION
Immediate family members of individuals who have died in military service use this form to request a Gold Star license plate.
PLATE INFORMATION
Louisiana legislation provides that immediate family members of persons who have died in military service to their country can
apply for special Gold Star license plates by submitting a copy of the death certificate of the armed forces member who lost his
life. The license plate can be used upon personally or jointly owned private passenger cars, pickup trucks, vans, motorcycles,
and recreational vehicles registered in the name, or jointly in the name, of the member making application. Check the
applicable condition.
During World War I, World War II, or any subsequent period of armed hostilities in which the United States was engaged
before July 1, 1958, or
Anytime after June 30, 1958:
a. while engaged in an action against an enemy of the United States;
b. while engaged in military operations involving conflict with an opposing foreign force;
c. while serving with friendly forces engaged in an armed conflict in which the United States is not a belligerent
party against an opposing armed force; or
Anytime after March 28, 1973, as a result of:
a. an international terrorist attack against the United States or a foreign nation friendly to the United States,
recognized as such an attack by the U.S. Secretary of Defense; or
b. military operations while serving outside the United States, including commonwealths, territories, and
possessions of the United States, as part of a peacekeeping force.
APPLICANT INFORMATION
APPLICANT NAME
DECEASED SERVICE MEMBER NAME
APPLICANT RELATIONSHIP TO DECEASED SERVICE MEMBER (check applicable box)
Foster parents who stood in loco parentis
Brother
Widow (remarried or not)
Stepmother
Widower (remarried or not)
Stepfather
Child
Half brother
Stepchild
Sister
Mother
Mother through adoption
Adopted child
Half sister
Father
Father through adoption
CERTIFICATION
I hereby certify that the information contained in this certification is true and correct to the best of my knowledge. I
understand that it is unlawful to knowingly make a false statement and any violation may be prosecuted as a felony as
provided in Louisiana law.
APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
DPSMV 1912 (R 03/09)