"Release Form for One/Two Year Affidavit" - Nebraska

Release Form for One/Two Year Affidavit 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.

ADVERTISEMENT
ADVERTISEMENT

Download "Release Form for One/Two Year Affidavit" - Nebraska

1299 times
Rate (4.5 / 5) 65 votes
RELEASE FORM FOR ONE/TWO YEAR AFFIDAVIT
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
The undersigned, being first duly sworn, depose and state, that I was the operator in a motor vehicle
√) the appropriate:
accident in the State of Nebraska on the above-mentioned date. Please check (
One (1) year has elapsed since the date of the
(√)
(√)
Two (2) years have elapsed since the date of the
Default in Payment on the Agreement you signed
accident (the accident must be at least two [2]
(the suspension for Default must be a least one [1]
years old before you sign this release).
year old before you sign this release).
During this time period, no action has been instituted in any court against me for any claim (from
damages and/or injuries) arising out of this accident. At this time I am requesting the reinstatement of
my operating privileges.
SIGNATURE BELOW MUST BE EITHER WITNESSED OR NOTARIZED:
Signature:
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 ONE/TWO YEAR AFFIDAVIT
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
The undersigned, being first duly sworn, depose and state, that I was the operator in a motor vehicle
√) the appropriate:
accident in the State of Nebraska on the above-mentioned date. Please check (
One (1) year has elapsed since the date of the
(√)
(√)
Two (2) years have elapsed since the date of the
Default in Payment on the Agreement you signed
accident (the accident must be at least two [2]
(the suspension for Default must be a least one [1]
years old before you sign this release).
year old before you sign this release).
During this time period, no action has been instituted in any court against me for any claim (from
damages and/or injuries) arising out of this accident. At this time I am requesting the reinstatement of
my operating privileges.
SIGNATURE BELOW MUST BE EITHER WITNESSED OR NOTARIZED:
Signature:
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