SR-LV-139E (2014/10) © Queen's Printer for Ontario, 2014 Page 1 of 2Disponible en français

Spouse Declaration and/or Plate Transfer Declaration

Office Use OnlyOffice Number Operator Number Effective Date (yyyy/mm/dd) Business Date (yyyy/mm/dd)

Method of PaymentCash Credit Card Cheque Debit

Fee Paid ($) Personal ID Viewed and Number Stock Issued

Spouse Declaration (Safety Standard Certificate and Drive Clean Pass Exemption)For the purpose of determining eligibility, “spouse” has the same meaning as in Part III of the Family Law Act, as stated below:

Either of two persons who:

(a) are married to each other; or

(b) have together entered into a marriage that is voidable or void, in good faith on the part of a person relying on this clause to assert any right;

or

Either of two persons who are not married to each other and have cohabited,

(a) continuously for a period of not less than three years; or

(b) in a relationship of some permanence, if they are the natural or adoptive parents of a child.

Spouse Declaration for the transfer of a vehicle bearingVehicle Identification Number (VIN)

WeLast Name, First Name

andLast Name, First Name

are spouses as defined in Part III of the Family Law Act stated above.

Signature Date (yyyy/mm/dd)

Signature Date (yyyy/mm/dd)

Stored Credit Transfer Declaration (If applicable, this section must only be completed if the Spouse Declaration above has also been completed.)

Donor and Recipient Section

I,Last Name, First Name

authorize the transfer of my stored credit onPlate Number

toLast Name, First Name Driver Licence/Registrant Identification Number

.

Signature Date (yyyy/mm/dd)

Signature Date (yyyy/mm/dd)

SR-LV-139E (2014/10) Page 2 of 2

Plate Transfer Declaration (Family Members only)

For the purpose of determining eligibility, for “plate transfer”, the ministry refers to the following:

Spouse/common-law spouseFather/mother, stepfather/stepmotherFather-in-law/mother-in-law, son-in-law/daughter-in-law Son/daughter, stepson/stepdaughter (including adopted children)Children and parents in a common-law relationship

Plate Owner Section

I,Last Name, First Name Driver Licence/Registrant Identification Number

authorize the transfer of my licence plate numberPlate Number

toLast Name, First Name

Date (yyyy/mm/dd)Plate Owner Signature

Recipient's Section

I,Last Name, First Name Driver Licence/Registrant Identification Number

acknowledge that licence platePlate Number

may go into plate denial for unpaid amounts incurred against the licence plate before and/or after the date of transfer. Should the licence plate go into plate denial, the licence plate will not be renewed and/or a new vehicle permit will not be issued until the applicable unpaid amounts are remitted. Applicable unpaid amounts may include charges in respect of Non Sufficient Funds cheques provided to the Ministry, unpaid fines and 407 tolls and related charges.

Date (yyyy/mm/dd)Recipient's Signature

Under provincial legislation, the penalty for making a false statement may include a fine and/or imprisonment and/or a driver’s licence suspension. Information on this form is collected under the authority of the Highway Traffic Act. If you have any questions about the collection and use of your personal information collected on this form, please call the Supervisor, Service Ontario at 416 235-2999 or 1 800 387-3445 or write to the Supervisor, Ministry of Transportation, Licensing Administration and Support Office, Main Floor, Building A, 1201 Wilson Avenue, Downsview ON M3M 1J8. Direct general inquiries to Service Ontario at 416 235-2999 or 1 800 387-3445 or visit ServiceOntario.ca.