"Affidavit to Report a Driver Who May Be Unable to Safely Operate a Motor Vehicle" - Connecticut

Affidavit to Report a Driver Who May Be Unable to Safely Operate a Motor Vehicle is a legal document that was released by the Connecticut Department of Motor Vehicles - a government authority operating within Connecticut.

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Download "Affidavit to Report a Driver Who May Be Unable to Safely Operate a Motor Vehicle" - Connecticut

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STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
60 STATE STREET
WETHERSFIELD, CONNECTICUT 06161-1013
On The Web At ct.gov/dmv
AFFIDAVIT
Instructions: To report an operator who may be unable to safely operate a motor vehicle, the following Affidavit must be completed in
its entirety and returned to the address noted below.
I,
, being duly sworn, have serious concerns about the ability of:
(Print your name)
Name:
Date of Birth:
(Print name)
Address:
(City)
(Zip Code)
(State)
to safely operate a motor vehicle, due to his/her medical condition. This Affidavit is based upon my personal observation and is made
under oath and subject to penalty of false statement.
Briefly describe the incident(s) which caused you to file this Affidavit:
Do you have a relationship with the operator you are reporting?
If yes, what is your relationship?
No
Yes
Are you aware of any medical condition(s) which may adversely affect this operator's ability to safely operate a motor vehicle?
If yes, please explain:
No
Yes
I swear or affirm under penalty of false statement in accordance with Connecticut General Statute 53a-157, and subject to penalties for
perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.
YOUR SIGNATURE
ADDRESS
CITY/STATE/ZIP CODE
PRINT NAME
TELEPHONE NUMBER
DATE
(
)
Subscribed and sworn to, before me, the undersigned officer, this
day of
, 20
.
Commissioner of the Superior Court, Juris No.:
Notary Public, My Commission Expires
/Notary Seal
Please mail this Affidavit to: Department of Motor Vehicles, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013.
The Affidavit will be reviewed to determine if any further action is required.
NOTE: THIS FORM IS SUBJECT TO DISCLOSURE TO THE LICENSEE
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
60 STATE STREET
WETHERSFIELD, CONNECTICUT 06161-1013
On The Web At ct.gov/dmv
AFFIDAVIT
Instructions: To report an operator who may be unable to safely operate a motor vehicle, the following Affidavit must be completed in
its entirety and returned to the address noted below.
I,
, being duly sworn, have serious concerns about the ability of:
(Print your name)
Name:
Date of Birth:
(Print name)
Address:
(City)
(Zip Code)
(State)
to safely operate a motor vehicle, due to his/her medical condition. This Affidavit is based upon my personal observation and is made
under oath and subject to penalty of false statement.
Briefly describe the incident(s) which caused you to file this Affidavit:
Do you have a relationship with the operator you are reporting?
If yes, what is your relationship?
No
Yes
Are you aware of any medical condition(s) which may adversely affect this operator's ability to safely operate a motor vehicle?
If yes, please explain:
No
Yes
I swear or affirm under penalty of false statement in accordance with Connecticut General Statute 53a-157, and subject to penalties for
perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.
YOUR SIGNATURE
ADDRESS
CITY/STATE/ZIP CODE
PRINT NAME
TELEPHONE NUMBER
DATE
(
)
Subscribed and sworn to, before me, the undersigned officer, this
day of
, 20
.
Commissioner of the Superior Court, Juris No.:
Notary Public, My Commission Expires
/Notary Seal
Please mail this Affidavit to: Department of Motor Vehicles, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013.
The Affidavit will be reviewed to determine if any further action is required.
NOTE: THIS FORM IS SUBJECT TO DISCLOSURE TO THE LICENSEE