"Statement of Lost Motor Vehicle Operator's License/Permit" - Nebraska

Statement of Lost Motor Vehicle Operator's License/Permit is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

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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 "Statement of Lost Motor Vehicle Operator's License/Permit" - Nebraska

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STATEMENT OF LOST
MOTOR VEHICLE OPERATOR’S LICENSE/PERMIT
NAME:
DATE OF BIRTH:
LICENSE NUMBER:
SOCIAL SECURITY NUMBER (OPTIONAL):
MAILING ADDRESS:
I depose and state that I have lost my Motor Vehicle Operator’s License and/or Permit listed
above. I fully realize that by making this affidavit the said Operator’s License and/or Permit
is null and void and may not be used for operating purposes.
SIGNATURE:
DATED:
WITNESS SIGNATURE:
DATED:
STATEMENT OF LOST
MOTOR VEHICLE OPERATOR’S LICENSE/PERMIT
NAME:
DATE OF BIRTH:
LICENSE NUMBER:
SOCIAL SECURITY NUMBER (OPTIONAL):
MAILING ADDRESS:
I depose and state that I have lost my Motor Vehicle Operator’s License and/or Permit listed
above. I fully realize that by making this affidavit the said Operator’s License and/or Permit
is null and void and may not be used for operating purposes.
SIGNATURE:
DATED:
WITNESS SIGNATURE:
DATED: