"Affidavit of Dormancy" - Nebraska

Affidavit of Dormancy 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 "Affidavit of Dormancy" - Nebraska

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AFFIDAVIT OF DORMANCY
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
COURT CASE/DOCKET NUMBER:
COUNTY/DISTRICT COURT OF (NAME OF COUNTY):
TERMS OF DORMANCY:
I hereby certify that the judgment rendered against me in the court listed above is hereby dormant (a judgment becomes
dormant [5] years from the date of the last execution [in some cases the date of judgment is the last execution] in the
court). Contact the court of jurisdiction to obtain the information required for the following two (2) lines:
Date judgment was filed:
Date of last execution / garnishment / action in the court:
YOU MUST INDICATE A MINIMUM FIVE (5) YEAR TIME PERIOD BETWEEN THE DATE OF LAST EXECUTION /
GARNISHMENT / ACTION IN THE COURT (LISTED ABOVE) AND THE DATE OF DORMANCY (LISTED BELOW):
Date of Dormancy:
At this time I am requesting the reinstatement of my operating privileges. I further understand that if the Judgment is
revived within the next ten (10) years, I could be subject to a subsequent suspension for this judgment.
SIGNATURE BELOW MUST NOTARIZED:
Signature:
Date:
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: Affidavit is VOID unless signature has been 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
AFFIDAVIT OF DORMANCY
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
COURT CASE/DOCKET NUMBER:
COUNTY/DISTRICT COURT OF (NAME OF COUNTY):
TERMS OF DORMANCY:
I hereby certify that the judgment rendered against me in the court listed above is hereby dormant (a judgment becomes
dormant [5] years from the date of the last execution [in some cases the date of judgment is the last execution] in the
court). Contact the court of jurisdiction to obtain the information required for the following two (2) lines:
Date judgment was filed:
Date of last execution / garnishment / action in the court:
YOU MUST INDICATE A MINIMUM FIVE (5) YEAR TIME PERIOD BETWEEN THE DATE OF LAST EXECUTION /
GARNISHMENT / ACTION IN THE COURT (LISTED ABOVE) AND THE DATE OF DORMANCY (LISTED BELOW):
Date of Dormancy:
At this time I am requesting the reinstatement of my operating privileges. I further understand that if the Judgment is
revived within the next ten (10) years, I could be subject to a subsequent suspension for this judgment.
SIGNATURE BELOW MUST NOTARIZED:
Signature:
Date:
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: Affidavit is VOID unless signature has been 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