"Release Form for Property Damage/Injury" - Nebraska

Release Form for Property Damage/Injury is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

Form Details:

  • Released on January 1, 2007;
  • The latest edition currently provided by the Nebraska Department of Motor Vehicles;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Motor Vehicles.

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Download "Release Form for Property Damage/Injury" - Nebraska

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RELEASE FORM FOR PROPERTY
DAMAGE/INJURY
SUSPENDED DRIVER’S PERSONAL INFORMATION (Please Print):
nd
rd
Last Name
First Name
Middle Initial
Suffix (Jr., Sr., 2
, 3
)
Current Mailing Address Required (Street or PO Box)
City
State
Zip Code
DATE OF BIRTH
DRIVER’S LICENSE NUMBER
SOCIAL SECURITY NUMBER (OPTIONAL)
Month
Day
Year
DATE OF LOSS / ACCIDENT
LOCATION OF LOSS / ACCIDENT
Month
Day
Year
TERMS OF RELEASE :
For valuable consideration received, the undersigned, being of legal age, hereby releases and forever discharges the
suspended driver for all claims (property damages and/or personal injuries) and/or causes of action arising from the motor
vehicle accident listed above.
Date payment for full restitution received:
SIGNATURE BELOW MUST BE EITHER WITNESSED OR NOTARIZED:
Other Party (individual, insurance company, attorney, etc.) Signature:
Title of Position (for insurance company, attorney, etc.):
Signing on behalf of (for insurance company, attorney, subrogee of, etc.):
Date:
Witness Signature (Must be a non-interested party):
Notary:
State of ________________________
County of ______________________
The foregoing instrument was acknowledged before me this _______ day of __________________, 20_____ by:
__________________________________________
Name of other party or representative
________________________________
Notary Public Signature
↑Affix seal here↑
Note: Release is VOID unless all signatures are either witnessed or notarized.
RETURN TO:
Department of Motor Vehicles
Phone:
(402) 471-3985
Financial Responsibility Division
Fax:
(402) 471-8288
P.O. Box 94877
Lincoln, Nebraska 68509-4877
DMV Web Site: http://www.dmv.state.ne.us
Neb. Rev. Stat. 60-510(4)
REV 01/2007
RELEASE FORM FOR PROPERTY
DAMAGE/INJURY
SUSPENDED DRIVER’S PERSONAL INFORMATION (Please Print):
nd
rd
Last Name
First Name
Middle Initial
Suffix (Jr., Sr., 2
, 3
)
Current Mailing Address Required (Street or PO Box)
City
State
Zip Code
DATE OF BIRTH
DRIVER’S LICENSE NUMBER
SOCIAL SECURITY NUMBER (OPTIONAL)
Month
Day
Year
DATE OF LOSS / ACCIDENT
LOCATION OF LOSS / ACCIDENT
Month
Day
Year
TERMS OF RELEASE :
For valuable consideration received, the undersigned, being of legal age, hereby releases and forever discharges the
suspended driver for all claims (property damages and/or personal injuries) and/or causes of action arising from the motor
vehicle accident listed above.
Date payment for full restitution received:
SIGNATURE BELOW MUST BE EITHER WITNESSED OR NOTARIZED:
Other Party (individual, insurance company, attorney, etc.) Signature:
Title of Position (for insurance company, attorney, etc.):
Signing on behalf of (for insurance company, attorney, subrogee of, etc.):
Date:
Witness Signature (Must be a non-interested party):
Notary:
State of ________________________
County of ______________________
The foregoing instrument was acknowledged before me this _______ day of __________________, 20_____ by:
__________________________________________
Name of other party or representative
________________________________
Notary Public Signature
↑Affix seal here↑
Note: Release is VOID unless all signatures are either witnessed or notarized.
RETURN TO:
Department of Motor Vehicles
Phone:
(402) 471-3985
Financial Responsibility Division
Fax:
(402) 471-8288
P.O. Box 94877
Lincoln, Nebraska 68509-4877
DMV Web Site: http://www.dmv.state.ne.us
Neb. Rev. Stat. 60-510(4)
REV 01/2007