Form DS-104 APPLICATION FOR REPLACEMENT PLATES

U.S. Department of State
OFFICE OF FOREIGN MISSIONS
DIPLOMATIC MOTOR VEHICLE OFFICE

OMB Approval No. 1405-0105
Expires XX-XX-20XX
*Estimated burden 15 minutes

APPLICATION FOR REPLACEMENT PLATES
Country

SEE INSTRUCTIONS ON PAGE 2
ATTENTION: Application cannot be processed without completion of gray shaded areas.
Mission Type (Embassy, Consulate, UN, OAS, Other)

License Plate Number

Reason for New Plates (Check one box)
1 Plate lost/stolen

2 Plates lost/stolen

Vehicle stolen
FOR OFFICE USE ONLY
Do Not Write
in this space

Change in position: New position
Other (Specify reason)

Fee

Date Plates Lost/Stolen (mm-dd-yyyy)

OFM Report Number

Owner Name (Surname)

I.D. Number

P

(First)

Date of Birth (mm-dd-yyyy)

(MI.)

Visa

Title Moved to
Name

Principal
Dependent

Address (Number, Street, Apartment, City, State, Zip Code)
I.D. Number
Co-owner Name (Surname)

I.D. Number

(First)

Date of Birth (mm-dd-yyyy)

(MI.)

Visa

Principal
Dependent

Vehicle Identification Number
Body

Year

Weight

Make

Model

Odometer

Color

Tag Number

(Insurance OK)
Lien Holder/Legal Owner (Name in Full) If the registered owner is the legal owner, write NONE.

Production Dates

Address

The undersigned certifies that, in accordance with the provisions of Title 18 U.S. Code, Section 1001,
prohibiting the making of false statements in connection with a federal matter, the information stated
here is true and correct.
Authorized Signature(s)

Date(s) (mm-dd-yyyy)

(MISSION SEAL)

DS-104
11-2017

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INSTRUCTIONS
1. Immediately report lost/stolen plates or a stolen vehicle to OFM at 202-895-3521 between 8 am- 5pm or at 571-345-3146 outside business
hours.
2. Type all answers, or write them in block letters.
3. Always write names with surname first, then first name, then middle name or initial. Spell your name exactly as it was given to the
Department of State. Applications with names different from the accreditation record will be returned for correction.
4. When writing dates month first, then day, then year (mm-dd-yyyy). Always write the month and give the day and year in numbers only.
Always give your date of birth (DOB) exactly as it was given to the Department of State. Applications with a date of birth different from the
accreditation record will be returned for correction.
5. Give your current residence address. A duty address is unacceptable unless you live at that address.
6. Copy all the motor vehicle information from the Certificate of Origin or Title. Be very careful when copying the vehicle identification number
(VIN).
7. The application must show an authorized signature: for personal vehicles, the owner (and co-owner if applicable); for mission vehicles, the
appropriate administrative officer.
8. The application must bear the mission seal.

OFFICE OF FOREIGN MISSIONS USE ONLY
NOTATIONS (Please include the date and your initials.)

OFM USE ONLY

Time/Date (mm-dd-yyyy) Received
PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular Relations
of 1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a)); Foreign Missions Act of 1982
(22 U.S.C. 4301-4316) as amended.
PURPOSE: The information solicited on this form will be used to adjudicate requests for replacement plates for foreign diplomatic motor vehicles.
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other
statutorily authorized purposes as covered under STATE 36, Security Records. This information also may be provided to the employing foreign
government or international organization.
DISCLOSURE: Providing this information is voluntary; Failure to provide the information requested on this form may result in denial of replacement
plates for foreign diplomatic motor vehicles.
PAPERWORK REDUCTION ACT STATEMENT
*Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection.
You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the
accuracy of this burden estimate and/or recommendations for reducing it, please send them to: M/OFM, 3507 International Place NW, Washington,
DC 20008.
DS-104

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