Form VSD669 "Affirmation for Gold Star License Plates" - Illinois

What Is Form VSD669?

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

Form Details:

  • Released on October 1, 2014;
  • The latest edition provided by the Illinois Secretary of State;
  • 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 VSD669 by clicking the link below or browse more documents and templates provided by the Illinois Secretary of State.

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Download Form VSD669 "Affirmation for Gold Star License Plates" - Illinois

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Secretary of State
ffirmation for Gold Star License Plates
Secretary of State
Vehicle Services Department
Special Plates Division
This request may only be processed in the Springfield
501 S. Second St.
office. Please apply in person or mail the required
541 Howlett Bldg.
documentation to the address at left.
Springfield, IL 62756
Section 5/3-664 of the Illinois Vehicle Code states: The Secretary of State shall issue registration plates designated as Gold
Star license plates to any Illinois resident who is the surviving widow, widower, parent, daughter, son or sibling of a person
who served in the Armed Forces of the United States and lost his or her life while in service whether in peacetime or war.
Applicant’s relationship to deceased service member:
❏ Widow
❏ Widower
❏ Sibling
❏ Son
❏ Mother
❏ Father
❏ Daughter
Service Member’s Name: ______________________________________________________________________________
I hereby affirm that I have received the Gold Star Medal and that I am in compliance with Section 5/3-664 of the Illinois
Vehicle Code.
__________________________________________________________________________________________________
Printed Name
__________________________________________________________________________________________________
Signature
Date
Printed by authority of the State of Illinois. October 2014 — 1 — VSD 669.3
Print
Reset
Save
Secretary of State
ffirmation for Gold Star License Plates
Secretary of State
Vehicle Services Department
Special Plates Division
This request may only be processed in the Springfield
501 S. Second St.
office. Please apply in person or mail the required
541 Howlett Bldg.
documentation to the address at left.
Springfield, IL 62756
Section 5/3-664 of the Illinois Vehicle Code states: The Secretary of State shall issue registration plates designated as Gold
Star license plates to any Illinois resident who is the surviving widow, widower, parent, daughter, son or sibling of a person
who served in the Armed Forces of the United States and lost his or her life while in service whether in peacetime or war.
Applicant’s relationship to deceased service member:
❏ Widow
❏ Widower
❏ Sibling
❏ Son
❏ Mother
❏ Father
❏ Daughter
Service Member’s Name: ______________________________________________________________________________
I hereby affirm that I have received the Gold Star Medal and that I am in compliance with Section 5/3-664 of the Illinois
Vehicle Code.
__________________________________________________________________________________________________
Printed Name
__________________________________________________________________________________________________
Signature
Date
Printed by authority of the State of Illinois. October 2014 — 1 — VSD 669.3