Get PA MV-371 2016-2024

MV-371 9-13 A. B. C. D. E. APPLICANT S LAST NAME STREET ADDRESS CO-APPLICANT S LAST NAME TITLE NUMBER APPLICATION FOR A RETIRED PERSON S 10. 00 PROCESSING FEE ON A VEHICLE REGISTRATION ELIGIBILITY INFORMATION ON REVERSE FIRST NAME VEHICLE IDENTIFICATION NO CITY MIDDLE NAME MAKE OF VEHICLE INCOME INFORMATION PA DL/PHOTO ID STATE DATE OF BIRTH ZIP REGISTRATION PLATE NO Total Gross Income During the Past Calender Year 1. SOCIAL SECURITY SSI PAYMENTS RETIREMENT BENEFITS. 2. PENSIONS AND ANNUITIES. 3. INTEREST DIVIDENDS AND CAPITAL GAINS. 4. OTHER INCOME. Total Income Did you pay the 10 Processing Fee for your last renewal Yes No Add 1 thru 4 I certify under penalty of law that ALL information contained herein is TRUE and CORRECT and that I am retired and receiving Social Security and/or other pension and income as listed in Section D. My total gross income for the previous year did not exceed 19 200 and unless I am physically or mentally incapable of driving I am the principal driver of this vehicle. I further certify that my signature authorizes the PA Department of Transportation to verify my/our income and that my occupation is retired through Internal Revenue Service income tax filings and that I understand that any misstatement of fact is a misdemeanor of the third degree punishable by a fine up to 2 500 and/or imprisonment up to 1 year 18 PA. C. S* Section 4904 b. Applicant Signature ELIGIBILITY REQUIREMENTS AND INSTRUCTIONS FOR THE 10. 00 PROCESSING FEE 1. You must be retired and receiving Social Security or other pension as described in Section D on the front of this application regardless of age. Part-time employment is permitted if you are retired from your principal occupation* If you receive only unemployment compensation or public assistance or are a student or other individual who is not retired you do not qualify. 2. Total gross income from all sources must not exceed 19 200. Other income includes Business/Rental Income Wages Public Assistance and Unemployment Compensation* 3. If only a husband or wife qualify the vehicle must be titled and registered in that individual s name or in both names jointly. If both husband and wife qualify each may register one vehicle for the 10 processing fee. One or both vehicles may be titled and registered in both names jointly. NOTE The applicant must be the principal driver of the vehicle unless physically or mentally incapable of driving. 4. Qualified applicants are limited to only one passenger vehicle or truck with a registered gross weight not more than 9 000 lbs. that may be registered for the 10 processing fee. 5. This application must be submitted in conjunction with Form MV-1 MV-4ST MV-105 MV-120 or MV-140. 6. NOTE Individuals should list their PA Driver s License PA DL or Photo ID in the space provided* Return the completed application with your vehicle registration application and include a 10 check or money order made payable to PA Department of Transportation* DO NOT SEND CASH. 00 PROCESSING FEE ON A VEHICLE REGISTRATION ELIGIBILITY INFORMATION ON REVERSE FIRST NAME VEHICLE IDENTIFICATION NO CITY MIDDLE NAME MAKE OF VEHICLE INCOME INFORMATION PA DL/PHOTO ID STATE DATE OF BIRTH ZIP REGISTRATION PLATE NO Total Gross Income During the Past Calender Year 1. SOCIAL SECURITY SSI PAYMENTS RETIREMENT BENEFITS. 2. PENSIONS AND ANNUITIES. 3. INTEREST DIVIDENDS AND CAPITAL GAINS.