CompIeted Entry Forms Must Be MaiIed To:

(Hand-delivered entry forms will not be accepted)

Registry of Motor Vehicles Attn: Lottery Plates P.O. Box 55889 Boston, MA 02205-5889

Massachusetts Drivers License Number: ____________________________________________________

Name of Applicant: _____________________________________________________________________
Last First Middle

Address: ______________________________City: MA Zip: ___________________
Street Apt#

Check here if new address: Yes, please update

*EmaiI Address: __________________________________ *Daytime Phone: ______________________

Current Massachusetts Passenger Plate Number & Plate Type As It Appears On Your

Registration Certificate: __________________________ (Limited to: PAN, PAS, PAR, PAV, PAY)

Leased Vehicle: Yes No If yes, name of leasing company: ________________________________

Lottery RuIes and EIigibiIity Requirements
i Only one (1) entry per applicant will be accepted, regardless of the number of active registrations he/she may have.
i An applicant must be a Massachusetts resident. An applicant must have a currently registered and insured passenger vehicle.
i Companies/Corporations may not apply.
i MassDot (Registry of Motor Vehicles, Highway, Mass Transit, and Aeronautics) employees, including contract employees, and their immediate family
members are not eligible. (Blacks Law Dictionary defines immediate family member as the term generally referring to ones parents, spouse,
children, and brothers & sisters.).
i Entry forms must be IegibIe and printed in ink. The form must not have any missing information. Incomplete or illegible forms will be rejected. It may
be helpful to have your registration in front of you when completing this entry form. Your accuracy will reduce the risk of your entry form being
rejected. *Fields marked with an (*) are optional. We encourage you to complete these fields in the event we need to contact you.
i Requests for specific plate numbers will not be honored. Eligible applicants will be considered for all plates listed. Plates will be awarded in the
order in which they are listed on the 2012 Plate List.
i An applicants registration and license cannot be in a non-renewal, suspended, or revoked status at the time of entry, the time of the drawing, or the
time of the plate swap. As such, an applicant must not have any outstanding excise taxes, parking tickets, child support, warrants, or unpaid fast lane
violations.
i Entry forms must be maiIed and postmarked no later than August 13, 2012. Hand-delivered entry forms will not be accepted.
i By law, lottery winners must be announced by September 15, 2012. Lottery results will be available on the RMV website: www.mass.gov/rmv
i All winners will be notified by the RMV in writing with instructions on how to transfer their current registration to their new lottery plate. Winners will
have until December 31, 2012 to swap his/her plate by phone or at the Special Plate Section at RMV Headquarters. Unclaimed plates will be forfeited
after December 31st. PIates wiII be registered to the winning appIicant onIy.
i All plates remain the property of the RMV even after registration.

I certify that I am a resident of Massachusetts and the holder of the passenger vehicle registration identified above. I further certify that this is the only
Lottery Plate Application I have filed for this drawing and I understand that I will be disqualified from participating in the drawing or, if I win a Lottery Plate,
the Registrar may deny the awarding of the Lottery Plate or revoke the registration if it is determined that I was not qualified at the time of the drawing. In
the event that I win a Lottery Plate, I hereby authorize the RMV to publish my name, town of residence, and the winning Lottery Plate number.

Signature: Date:

The 2012 MassDOT Registry of Motor Vehicles Division
PLATE LOTTERY ENTRY FORM
T21843_0612
AvaiIabIe PIates for the RMV 2012 PIate Lottery
Listed below are the 124 Passenger Reserve Plates expected to be available for the 2012 Plate Lottery.