Form AOC-492.A "Affidavit for Hardship License" - Kentucky

What Is Form AOC-492.A?

This is a legal form that was released by the Kentucky Court of Justice - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Kentucky Court of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AOC-492.A by clicking the link below or browse more documents and templates provided by the Kentucky Court of Justice.

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Download Form AOC-492.A "Affidavit for Hardship License" - Kentucky

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AOC- 492.A
Doc. Code: AFHD
Case No. ____________________
Rev. 5-16
Page 1 of 2
l e x
Court
____________________
e t
j u s t i t i a
Commonwealth of Kentucky
County
____________________
Court of Justice
www.courts.ky.gov
Division
____________________
KRS 189A.400-.460
Affidavit For Hardship License
COMMONWEALTH OF KENTUCKY
PLAINTIFF
VS.
_______________________________________________
DEFENDANT
The undersigned Affiant is the [ ] employer/self employed, [ ] educator, [ ] physician, or [ ] ADE
program director for the above-named Defendant. Pursuant to KRS 189A.410 (see page 2), the undersigned states
under oath that the above-named Defendant should be granted a hardship driver’s license for the reason(s) stated
below, including the specific days and times when the Defendant is required to drive.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
If Employer/self-employed please provide the following information: Affiant’s Business/Employer’s name and address,
Affiant’s title, Affiant’s phone number on page 2.
Driving is necessary on the following days and at these specified times:
From:
To:
Mon.
______________________ m.
____________________ m.
Tues.
______________________ m.
____________________ m.
Wed.
______________________ m.
____________________ m.
Thurs. ______________________ m.
____________________ m.
Fri.
______________________ m.
____________________ m.
Sat.
______________________ m.
____________________ m.
Sun.
______________________ m.
____________________ m.
WHEREFORE, Affiant prays that the above-named Defendant’s Application for Hardship Driver’s License
NOTICE: Pursuant to KRS 189A.440(3), knowingly assisting Defendant in making a false application
be granted.
statement is a Class A Misdemeanor and results in revocation of the person’s operator’s license for six (6) months.
___________________________________________
___________________________________________
Affiant’s Name
Affiant’s Signature
(Please Print)
Subscribed and sworn to before me by the Affiant, this ______ day of ______________________, 2_______.
My commission expires: __________________, 2_______.
______________________________________
Notary Public
AOC- 492.A
Doc. Code: AFHD
Case No. ____________________
Rev. 5-16
Page 1 of 2
l e x
Court
____________________
e t
j u s t i t i a
Commonwealth of Kentucky
County
____________________
Court of Justice
www.courts.ky.gov
Division
____________________
KRS 189A.400-.460
Affidavit For Hardship License
COMMONWEALTH OF KENTUCKY
PLAINTIFF
VS.
_______________________________________________
DEFENDANT
The undersigned Affiant is the [ ] employer/self employed, [ ] educator, [ ] physician, or [ ] ADE
program director for the above-named Defendant. Pursuant to KRS 189A.410 (see page 2), the undersigned states
under oath that the above-named Defendant should be granted a hardship driver’s license for the reason(s) stated
below, including the specific days and times when the Defendant is required to drive.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
If Employer/self-employed please provide the following information: Affiant’s Business/Employer’s name and address,
Affiant’s title, Affiant’s phone number on page 2.
Driving is necessary on the following days and at these specified times:
From:
To:
Mon.
______________________ m.
____________________ m.
Tues.
______________________ m.
____________________ m.
Wed.
______________________ m.
____________________ m.
Thurs. ______________________ m.
____________________ m.
Fri.
______________________ m.
____________________ m.
Sat.
______________________ m.
____________________ m.
Sun.
______________________ m.
____________________ m.
WHEREFORE, Affiant prays that the above-named Defendant’s Application for Hardship Driver’s License
NOTICE: Pursuant to KRS 189A.440(3), knowingly assisting Defendant in making a false application
be granted.
statement is a Class A Misdemeanor and results in revocation of the person’s operator’s license for six (6) months.
___________________________________________
___________________________________________
Affiant’s Name
Affiant’s Signature
(Please Print)
Subscribed and sworn to before me by the Affiant, this ______ day of ______________________, 2_______.
My commission expires: __________________, 2_______.
______________________________________
Notary Public
AOC-492.A
Rev. 5-16
Page 2 of 2
If Employer/self-employed please provide the following information:
Affiant’s Business/Employer’s Name
_______________________________________________________________
Affiant’s Business/Employer’s Address _______________________________________________________________
_______________________________________________________________
Affiant’s Title ____________________________________________________________________________________
Affiant’s Phone ___________________________________
INFORMATION REQUIRED PURSUANT TO KRS 189A.410
FOR ISSUANCE OF HARDSHIP LICENSE
1. If the license is sought for employment purposes: A written, sworn statement from your employer
detailing your job, hours of employment, and the necessity for you to use a motor vehicle either in work
at the direction of your employer during work hours, or in travel to and from work. If you are self-employed,
provide the described information together with a sworn and notarized statement attesting to the truth
of the above information.
2. If the license is sought for education purposes: A written, sworn statement from the school or
educational institution that you attend containing your class schedule, courses being taken, and
necessity for you to use a motor vehicle in travel to and from school or other educational institution.
A license for educational purposes shall not include participation in sports, social, extracurricular,
fraternal or other noneducational activities.
3. If the license is sought for medical purposes: A written, sworn statement from a physician or other
medical professional licensed (but not certified) under Kentucky laws, attesting to your normal hours of
treatment, and the necessity to use a motor vehicle to travel to and from the treatment.
4. If the license is sought for alcohol or substance abuse education or treatment purposes: A written,
sworn statement from the director of any alcohol or substance abuse education or treatment program
as to the hours in which you are expected to participate in the program, the nature of the program, and
the necessity for you to use a motor vehicle to travel to and from the program.
5. If the license is sought for court-ordered counseling or other programs: A copy of any court order
relating to treatment, participation in driver improvement programs, or other terms and conditions
ordered by the court relating to you which require you to use a motor vehicle in traveling to and from the
court-ordered program. The court order must include the necessity for use of a motor vehicle.
6. A sworn statement must be signed by a notary public.
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