Form DSD FR9.2 "Out-of-State Affidavit / Financial Responsibility Insurance Waiver" - Illinois

What Is Form DSD FR9.2?

This is a legal form that was released by the Illinois Secretary of State - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2013;
  • The latest edition provided by the Illinois Secretary of State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DSD FR9.2 by clicking the link below or browse more documents and templates provided by the Illinois Secretary of State.

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Download Form DSD FR9.2 "Out-of-State Affidavit / Financial Responsibility Insurance Waiver" - Illinois

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FINANCIAL RESPONSIBILITY SECTION
Office of the Secretar y of State
2701 S. DIRKSEN PKWY.
SPRINGFIELD, IL 62723
217-782-3720
Driver Ser vices Depar tment
www.cyberdriveillinois.com
Out-of-State Affidavit / Financial Responsibility Insurance Waiver
THIS FORM MUST BE MAILED
SEPARATELY TO THE ADDRESS BELOW.
Former Illinois Driver’s License Number ______________________________________________________________
New Driver’s License Number (if applicable) ___________________________________________________________
Full Name:
Last
First
Middle
Current Street Address:
City
State
ZIP
County
Prior Illinois Street Address:
City
ZIP
County
Sex:
Date of Birth:
Month
Day
Year
Social Security Number
Daytime Telphone Number
c
c
Male
Female
(________) ________- ______________
I hereby affirm that I am no longer a resident of the State of Illinois, and I am requesting that I be relieved of the require-
ment to file Proof of Financial Responsibility in Illinois as outlined in Public Act 94-0224.
I hereby affirm that the information provided is true and correct.
__________________________________________________________
_________________________________
Signature
Date
Once this request has been processed and accepted you will be notified in writing. Please allow ample time for processing.
You are hereby advised that your Illinois driver’s license will be canceled in 60 days from the date of processing. If you
return to Illinois in the next three years, you will be required to file proof of insurance in the form of an SR22 Certificate
before issuance of a new Illinois driver’s license.
Illinois Secretary of State
Driver Services Department
THIS FORM MUST BE SIGNED, DATED
Financial Responsibility Section
AND MAILED DIRECTLY TO THIS ADDRESS:
2701 S. Dirksen Pkwy.
Springfield, IL 62723
Phone: 217-782-3720
Printed by authority of the State of Illinois. September 2013 — 10M — DSD FR 9.2
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FINANCIAL RESPONSIBILITY SECTION
Office of the Secretar y of State
2701 S. DIRKSEN PKWY.
SPRINGFIELD, IL 62723
217-782-3720
Driver Ser vices Depar tment
www.cyberdriveillinois.com
Out-of-State Affidavit / Financial Responsibility Insurance Waiver
THIS FORM MUST BE MAILED
SEPARATELY TO THE ADDRESS BELOW.
Former Illinois Driver’s License Number ______________________________________________________________
New Driver’s License Number (if applicable) ___________________________________________________________
Full Name:
Last
First
Middle
Current Street Address:
City
State
ZIP
County
Prior Illinois Street Address:
City
ZIP
County
Sex:
Date of Birth:
Month
Day
Year
Social Security Number
Daytime Telphone Number
c
c
Male
Female
(________) ________- ______________
I hereby affirm that I am no longer a resident of the State of Illinois, and I am requesting that I be relieved of the require-
ment to file Proof of Financial Responsibility in Illinois as outlined in Public Act 94-0224.
I hereby affirm that the information provided is true and correct.
__________________________________________________________
_________________________________
Signature
Date
Once this request has been processed and accepted you will be notified in writing. Please allow ample time for processing.
You are hereby advised that your Illinois driver’s license will be canceled in 60 days from the date of processing. If you
return to Illinois in the next three years, you will be required to file proof of insurance in the form of an SR22 Certificate
before issuance of a new Illinois driver’s license.
Illinois Secretary of State
Driver Services Department
THIS FORM MUST BE SIGNED, DATED
Financial Responsibility Section
AND MAILED DIRECTLY TO THIS ADDRESS:
2701 S. Dirksen Pkwy.
Springfield, IL 62723
Phone: 217-782-3720
Printed by authority of the State of Illinois. September 2013 — 10M — DSD FR 9.2