DEPARTMENT OF VETERANS AFFAIRS                          Telephone:    317/232-3910
302 West Washington Street, Room E-120                  Fax:          317/232-7721
Indianapolis, Indiana 46204-2738
State Form 32584  (R4/3-97)

Veteran's Name ___________________________________________________________________

Street Address ___________________________________________________________________

City ______________________________________    State ________    Zip _____________

VA Claim Number ______________________   Social Security Number __________________

I request certification for the following license plate:

_____ Disabled                 _____ Ex-POW              _____ Purple Heart

Veteran's Signature ______________________________________________________________
                    (Authorizes the release of information to confirm eligibility)

Once the application is completed, either send or fax it to the Indiana Department 
of Veterans Affairs (address and fax numbers listed above). The Purple Heart license 
plate application must have documentation with the application. Approved applications 
are returned only by mail; they cannot be faxed back to the applicant.  You do not 
need to reapply for certification once this form has been approved, except for the 
Disabled Veteran license plate and then only if your disability status changes.
*The Hoosier Veteran license plate may be approved at your local license branch and 
does not require a form.  You must present your DD 214 or discharge showing an 
honorable or under honorable conditions discharge.

To be completed by Indiana Department of Veterans Affairs

None of the veteran license plates below may be issued without this form, as approved 
by the Indiana Department of Veterans Affairs.  Forms approved by the Indiana 
Department of Veterans Affairs will have an embossed seal.  Forms without the embossed 
seal are not valid.

According to records available, the above-named veteran, is ___/is not _____ entitled 
to the license plate(s) indicated below:

_____  Class I - 100% Disabled Veteran            _____  Class II - Disabled Veteran

_____  Ex-POW                                     _____  Purple Heart

Approving Authority Signature _______________________________  Date  ________________