"Installment Agreement Form (Unsatisfied Judgment Related Suspensions Only)" - Nebraska

Installment Agreement Form (Unsatisfied Judgment Related Suspensions Only) is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

Form Details:

  • Released on February 1, 2006;
  • 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 "Installment Agreement Form (Unsatisfied Judgment Related Suspensions Only)" - Nebraska

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INSTALLMENT AGREEMENT FORM
(UNSATISFIED JUDGMENT RELATED SUSPENSIONS ONLY)
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
City
State
Zip Code
Box)
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
COURT DESCRIPTION:
Court Case Number:
Court of Jurisdiction:
Plaintiff:
Defendant:
TERMS OF THE AGREEMENT:
Total dollar amount due or financed:
$
Weekly:
Monthly:
Yearly:
Frequency of payments (√ applicable):
(√)
(√)
(√)
Dollar amount of each payment:
$
Date of first payment:
Month
Day
Year
SIGNATURES BELOW MUST BE EITHER WITNESSED OR NOTARIZED:
Suspended Driver’s Signature:
Other Party (individual, insurance company, attorney, etc.) Signature:
Mailing Address:
Title of Position (for insurance company, attorney, etc.):
Signing on behalf of (for insurance company, attorney, etc.):
Notary:
Notary:
State of ________________________
State of ________________________
County of ______________________
County of ______________________
The foregoing instrument was acknowledged before me this
The foregoing instrument was acknowledged before me this
______ day of _________________, 20_____ by:
_______ day of __________________, 20_____ by:
________________________________________
__________________________________________
Name of suspended driver
Name of other party or representative
______________________________
________________________________
↑Affix seal here↑
Notary Public Signature
↑Affix seal here↑
Notary Public Signature
Note: Installment Agreement is VOID unless it has been filed with the court of jurisdiction and certified
by the court of jurisdiction (court of jurisdiction means the court the issued the judgment order).
Certification:
Neb. Rev. Stat. 60-521 and 60-522
- OVER / NEXT PAGE-
INSTALLMENT AGREEMENT FORM
(UNSATISFIED JUDGMENT RELATED SUSPENSIONS ONLY)
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
City
State
Zip Code
Box)
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
COURT DESCRIPTION:
Court Case Number:
Court of Jurisdiction:
Plaintiff:
Defendant:
TERMS OF THE AGREEMENT:
Total dollar amount due or financed:
$
Weekly:
Monthly:
Yearly:
Frequency of payments (√ applicable):
(√)
(√)
(√)
Dollar amount of each payment:
$
Date of first payment:
Month
Day
Year
SIGNATURES BELOW MUST BE EITHER WITNESSED OR NOTARIZED:
Suspended Driver’s Signature:
Other Party (individual, insurance company, attorney, etc.) Signature:
Mailing Address:
Title of Position (for insurance company, attorney, etc.):
Signing on behalf of (for insurance company, attorney, etc.):
Notary:
Notary:
State of ________________________
State of ________________________
County of ______________________
County of ______________________
The foregoing instrument was acknowledged before me this
The foregoing instrument was acknowledged before me this
______ day of _________________, 20_____ by:
_______ day of __________________, 20_____ by:
________________________________________
__________________________________________
Name of suspended driver
Name of other party or representative
______________________________
________________________________
↑Affix seal here↑
Notary Public Signature
↑Affix seal here↑
Notary Public Signature
Note: Installment Agreement is VOID unless it has been filed with the court of jurisdiction and certified
by the court of jurisdiction (court of jurisdiction means the court the issued the judgment order).
Certification:
Neb. Rev. Stat. 60-521 and 60-522
- OVER / NEXT PAGE-
In the event of nonpayment or default on this Installment Agreement, the individual or
company accepting payments will immediately advise the Department of Motor Vehicles of
such default and the Financial Responsibility Division will proceed with the suspension of the
operating privileges as specified in §§60-523.
Forward this form along with the other reinstatement requirements (if applicable) to the
Department of Motor Vehicles, Financial Responsibility Division, P.O. Box 94877, Lincoln,
Nebraska 68509-4877.
Upon receipt of the final payment, you will need to forward a certified copy of a
SATISFACTION OF JUDGMENT to the Department of Motor Vehicles, Financial
Responsibility Division, P.O. Box 94877, Lincoln, Nebraska 68509-4877.
Return completed agreement to:
Department of Motor Vehicles
Financial Responsibility Division
P.O. Box 94877
Lincoln, Nebraska 68509-4877
Phone: (402) 471-3985
Office Hours: 8:00 a.m. – 5:00 p.m. CST
Fax: (402) 471-8288
DMV Web Site: http://www.dmv.state.ne.us/
Printed on recycled paper
REV 02/2006
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