Form REG113 "Application for Gold Star Family Plates" - Massachusetts

What Is Form REG113?

This is a legal form that was released by the Massachusetts Registry of Motor Vehicles - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the Massachusetts Registry of Motor Vehicles;
  • 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 REG113 by clicking the link below or browse more documents and templates provided by the Massachusetts Registry of Motor Vehicles.

ADVERTISEMENT
ADVERTISEMENT

Download Form REG113 "Application for Gold Star Family Plates" - Massachusetts

Download PDF

Fill PDF online

Rate (4.7 / 5) 31 votes
Application for Gold Star Family Plates
Registry of Motor Vehicles
P.O. Box 55895  Boston, MA  02205-5895
Attn: Special Plates
A. Requirements and Instructions
A Gold Star Family Plate can be issued, without charge, to spouses, parents, children, siblings, grandparents, and grandchildren of soldiers who died while on
active duty with the Armed Forces of the United States. Each qualifying applicant can register one private passenger motor vehicle or motorcycle owned and
principally used by him/her.
Step-parents, step-children, step-siblings, step-grandparents, and step-grandchildren are not eligible unless a legal adoption occurred prior to the time of death.
An applicant for a Gold Star Family Plate must provide evidence that is satisfactory to the RMV demonstrating that the deceased died while on active duty with
the Armed Forces.
Eligibility for Gold Star Family Plates may be verified by the MA Department of Veterans' Services. If your surname is different than that of the deceased, the
Registrar may require additional proof of your relationship.
If you have any questions about eligibility, please contact the Special Plates Department at 857-368-8031.
Instructions:
1.
Complete this form and return it to a full-service RMV Service Center or mail it to the above address, along with
the following documentation (either an
original or a certified copy) as proof of eligibility. A photocopy will be retained by the RMV as part of the application.
a. A DD Form 1300 Report of Casualty, or
b. A telegram for World War II and Korean military members
2. You must also provide a completed Registration and Title Application (stamped by your insurance company). If you qualify, you will then be issued your
plates.
B. Applicant Information
Last Name
First Name
Middle Initial
Suffix
Address
Zip
Street
City
State
Code
Email Address
Phone #
Driver’s License #
Current Plate #
Last Name of Deceased Soldier
First Name
Middle Initial
Suffix
Date of Death
Branch of Service
 Mother  Father  Son  Daughter  Husband  Wife  Grandparent  Sibling  Grandchild
The deceased was my: (check one)
C. Vehicle Type
 Passenger Vehicle
 Motorcycle
 Check here for K.I.A. decal affixed to plate (see page 2 for eligibility requirements)
Check one:
D. Optional Personalized Plate Request
(maximum of 4 characters)
If you would like Gold Star Family Personalized Plates, please complete this section.
Gold Star Family Personalized Plate Requirements:
1. Plates must have 3 or 4 characters. These characters can be a combination of numbers or letters.
2. The first character can be a letter or a number from 1-9. The first character cannot be the number 0.
3. No periods, spaces, or punctuation marks are allowed.
4. Plates cannot be issued if they would appear to duplicate a registration already issued.
5. The Registrar may reject a requested combination for other reasons if she reasonably determines that issuance of the requested combination
would be inappropriate as a state-issued registration plate.
(maximum of 4 characters)
What is the significance of this combination of letters and/or numbers?
st
1
Choice: _____________________________________________
____________________________________________________________
2nd Choice: ____________________________________________
____________________________________________________________
3rd Choice: ____________________________________________
___________________________________________________________
p.1
REG113_1119
Application for Gold Star Family Plates
Registry of Motor Vehicles
P.O. Box 55895  Boston, MA  02205-5895
Attn: Special Plates
A. Requirements and Instructions
A Gold Star Family Plate can be issued, without charge, to spouses, parents, children, siblings, grandparents, and grandchildren of soldiers who died while on
active duty with the Armed Forces of the United States. Each qualifying applicant can register one private passenger motor vehicle or motorcycle owned and
principally used by him/her.
Step-parents, step-children, step-siblings, step-grandparents, and step-grandchildren are not eligible unless a legal adoption occurred prior to the time of death.
An applicant for a Gold Star Family Plate must provide evidence that is satisfactory to the RMV demonstrating that the deceased died while on active duty with
the Armed Forces.
Eligibility for Gold Star Family Plates may be verified by the MA Department of Veterans' Services. If your surname is different than that of the deceased, the
Registrar may require additional proof of your relationship.
If you have any questions about eligibility, please contact the Special Plates Department at 857-368-8031.
Instructions:
1.
Complete this form and return it to a full-service RMV Service Center or mail it to the above address, along with
the following documentation (either an
original or a certified copy) as proof of eligibility. A photocopy will be retained by the RMV as part of the application.
a. A DD Form 1300 Report of Casualty, or
b. A telegram for World War II and Korean military members
2. You must also provide a completed Registration and Title Application (stamped by your insurance company). If you qualify, you will then be issued your
plates.
B. Applicant Information
Last Name
First Name
Middle Initial
Suffix
Address
Zip
Street
City
State
Code
Email Address
Phone #
Driver’s License #
Current Plate #
Last Name of Deceased Soldier
First Name
Middle Initial
Suffix
Date of Death
Branch of Service
 Mother  Father  Son  Daughter  Husband  Wife  Grandparent  Sibling  Grandchild
The deceased was my: (check one)
C. Vehicle Type
 Passenger Vehicle
 Motorcycle
 Check here for K.I.A. decal affixed to plate (see page 2 for eligibility requirements)
Check one:
D. Optional Personalized Plate Request
(maximum of 4 characters)
If you would like Gold Star Family Personalized Plates, please complete this section.
Gold Star Family Personalized Plate Requirements:
1. Plates must have 3 or 4 characters. These characters can be a combination of numbers or letters.
2. The first character can be a letter or a number from 1-9. The first character cannot be the number 0.
3. No periods, spaces, or punctuation marks are allowed.
4. Plates cannot be issued if they would appear to duplicate a registration already issued.
5. The Registrar may reject a requested combination for other reasons if she reasonably determines that issuance of the requested combination
would be inappropriate as a state-issued registration plate.
(maximum of 4 characters)
What is the significance of this combination of letters and/or numbers?
st
1
Choice: _____________________________________________
____________________________________________________________
2nd Choice: ____________________________________________
____________________________________________________________
3rd Choice: ____________________________________________
___________________________________________________________
p.1
REG113_1119
E. Certification and Signature
I certify that I occupy the family relationship to the deceased soldier that I have indicated above and that, if a Gold Star Family Plate is issued to
me, it will be registered to a vehicle owned and principally used by me. I agree to abide by all rules, regulations, and policies of the RMV and all
rules, regulations, and policies of the Massachusetts Department of Veterans’ Services in regard to the registration and display of such plate.
I
swear (affirm), under the penalties of perjury, that the information I have provided is true and correct. I am aware that false statements are
punishable by fine, imprisonment, or both.
Signature: ________________________________________________________________________
Date: ______________________________
K.I.A. Decal Eligibility Requirements and Placement Information:
For a family member to be eligible for a K.I.A. Decal, the soldier's DD Form 1300 must
indicate “Killed in Action” in category box 4C.
K.I.A. Decals can be issued for both standard Gold Star Family Plates and for Gold Star
Family Personalized Plates.
K.I.A. Decals must be affixed to the shaded area of the plate below the Gold Star
sample Killed in Action decal
(on the left of the plate).
p.2
REG113_1119
Page of 2