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This is a Ohio form that can be used for Vehicle Registration within Statewide, Bureau Of Motor Vehicles.
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OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES AFFIDAVIT TO EXEMPT MOTOR VEHICLES OF VOLUNTEER RESCUE SERVICES FROM REGISTRATION FEES Section 4503.172 of the Ohio Revised Code (R.C.) provides for the issuance of Gratis Permanent License Plates for vehicles titled in the name of a volunteer rescue service certified by the Department of Public Safety, and used solely in the transaction of the business of the rescue service. AFFIDAVIT STATE OF OHIO, COUNTY OF OWNER STREET CITY ZIP CODE YEAR MAKE MODEL VEHICLE IDENTIFICATION NUMBER TITLE NUMBER Applicant being first duly sworn states that the above described vehicle is to be used solely in volunteer rescue service as defined in division (E) of Section 4765.01 of the R.C. and that the proper personnel have been certified by the Department of Public Safety. Applicant further states that he / she is authorized to act on behalf of the rescue services organization as defined in R.C. 4503.172(B) and has provided a list of all personnel employed by said service as emergency medical responders, emergency medical technicians, advanced emergency medical technicians and paramedics, along with their certification numbers to the executive director of the Ohio Department of Public Safety, Division of EMS for review. SIGNATURE DATE X Subscribed and sworn to in my presence by ___________________________ this ________day of ________________, in the county of ____________________________, state of __________________________. X_______________________________________ My commission expires:______________. Signature of Notary (Notary Seal) FOR BMV / EMS USE ONLY This rescue service organization as defined in R.C. 4503.172(B) has presented satisfactory evidence of certification by the Ohio Department of Public Safety, Division of EMS. APPROVED BY (PRINT NAME) APPROVED BY (SIGNATURE) X BMV 4523 4/15 [760-1512] American LegalNet, Inc. www.FormsWorkFlow.com