Form DS-101 APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)

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

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

FOR OFFICE USE ONLY
Do Not Write in this space

APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)
SEE INSTRUCTIONS ON REVERSE
ATTENTION: Application cannot be processed without completion of gray shaded areas.
1. Type all answers or write in block letter.
2. In addition to this form, you must submit (a) the Certificate of origin or the Vehicle Title and
(b) a photocopy of the insurance binder sheet or declaration page as proof of liability coverage.
Country

1. License Plate Number

Mission Type (Embassy, Consulate, UN, OAS, Other)

Owner Name (Surname, First, MI. - as given to Department of State)

I.D. Number

Date of Birth (mm-dd-yyyy)

Check Number

Visa

Principal

Fee

Dependent
Address (Number, Street, Apartment, City, State, Zip Code)

2. License Plate Number

Co-owner Name (Surname, First, MI. - as given to Department of State)

3. License Plate Number

I.D. Number

Date of Birth (mm-dd-yyyy)

Vehicle Identification Number
Body

Year

Weight

Visa

Principal

4. License Plate Number

Make

Dependent
Model

5. License Plate Number

Odometer

Color

I.D. Number (Check)

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

O

Address

C/O

Insurance Company Name

A

Address

Insurance Carrier

Broker/Agent Name and Address

Insurance Broker
Insurance Limits

Binder or Policy Number

Beginning Date (mm-dd-yyyy)
Expiration Date (mm-dd-yyyy)

Bodily Injury/Person

INSURANCE COVERAGE
Bodily Injury/Accident
Property Damage/Accident

Combined Single Unit

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. The
required insurance liability coverage will be maintained for all drivers of this vehicle at all times.
SPECIAL NOTE: Failure to maintain an insurance on this vehicle at the required liability limits
of $100,000 per person/$300,000 per accident/$100,000 property damage or $300,000
combined single limit for this vehicle will result in cancellation of registration and recall of the
official federal license plates.

(EMBASSY SEAL)

DS-101
11-2017

Owner's Signature

Date (mm-dd-yyyy)

Co-owner's Signature

Date (mm-dd-yyyy)

Page 1 of 2

INSTRUCTIONS
1. In addition to this form, you must submit:
a. The original ownership document(s): the Certificate of Origin (for a new vehicle) or the state's certificate of title (for a used vehicle) and all
corresponding re-assignment pages.
b. A photocopy of the insurance binder sheet or the declaration page. You must have liability coverage of $100,000 Bodily Injury/Person;
$300,000 Bodily Injury/Accident; $100,000 Property Damage/Accident; or $300,000 combined single limit
c. Odometer Statement complete with signatures of the buyer and seller (for new vehicles only).
2. You must 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. Always write dates month first, then day, then year. 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 state's certificate of title. Be very careful when copying the vehicle
identification number (VIN).
7. If applicable, provide the name and address of the bank or other institution with a financial interest (lien) in the motor vehicle.
8. You must sign and date the application, and it 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 registration of foreign missions members' personal
vehicle(s).
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 registration of
foreign missions members' personal vehicle(s).
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-101

Page 2 of 2