Form 40-5143 "Arizona Residency Affidavit" - Arizona

What Is Form 40-5143?

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

Form Details:

  • Released on April 1, 2021;
  • The latest edition provided by the Arizona Department of Transportation;
  • 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 40-5143 by clicking the link below or browse more documents and templates provided by the Arizona Department of Transportation.

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Download Form 40-5143 "Arizona Residency Affidavit" - Arizona

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ARIZONA RESIDENCY AFFIDAVIT
Clear
azdot.gov
40-5143 R04/21
The Arizona Residency Affidavit may be used as one acceptable document for proof of residency. The form is completed by
the applicant stating the address where they reside or by a representative or parent/guardian certifying for the applicant.
Section A – The applicant will complete this section to Self-Certify their Arizona Residential address
Or
Section B – Representative or Parent/Guardian will complete this section on behalf of applicant
o
Proof of residency for representative or parent/guardian is required
Travel Credential – This document may be used as one proof of residency and does require one additional proof
o
Secondary proof of residency must be issued by an agency other than ADOT
A. Self-Certification
The applicant for an Arizona driver license or identification card must complete Section A.
Name
Residence Address
City
State
ZIP Code
I hereby certify under penalty of perjury that all statements in this application are true and correct. I agree and understand that any
misstatement of material facts may cause cancellation and/or denial of my driver license or identification card. I further understand that it is a
Class 2 Misdemeanor (ARS 28-3478) to knowingly falsify information, make a false statement, conceal a material fact or otherwise commit
fraud in an application on a driver license application, or non-operating identification license or falsify information required by ARS 28-3165.
Applicant’s Signature
Date
B. Representative or Parent/Guardian Certification on behalf of Applicant
The Representative or Parent/Guardian must complete Section B.
Name of Representative or Parent/Guardian
Name of Applicant
Residence Address
City
State
ZIP Code
The representative or parent/guardian for the applicant must certify and sign the following section. I certify under penalty of perjury the
information submitted on behalf of the above applicant is true and correct. The applicant does live at my residence or receives services at the
location listed above. I understand that according to Arizona law, it is a crime to knowingly make any false statement relating to application
for a driver license or identification card.
Representative or Parent/Guardian Signature
Date
ARIZONA RESIDENCY AFFIDAVIT
Clear
azdot.gov
40-5143 R04/21
The Arizona Residency Affidavit may be used as one acceptable document for proof of residency. The form is completed by
the applicant stating the address where they reside or by a representative or parent/guardian certifying for the applicant.
Section A – The applicant will complete this section to Self-Certify their Arizona Residential address
Or
Section B – Representative or Parent/Guardian will complete this section on behalf of applicant
o
Proof of residency for representative or parent/guardian is required
Travel Credential – This document may be used as one proof of residency and does require one additional proof
o
Secondary proof of residency must be issued by an agency other than ADOT
A. Self-Certification
The applicant for an Arizona driver license or identification card must complete Section A.
Name
Residence Address
City
State
ZIP Code
I hereby certify under penalty of perjury that all statements in this application are true and correct. I agree and understand that any
misstatement of material facts may cause cancellation and/or denial of my driver license or identification card. I further understand that it is a
Class 2 Misdemeanor (ARS 28-3478) to knowingly falsify information, make a false statement, conceal a material fact or otherwise commit
fraud in an application on a driver license application, or non-operating identification license or falsify information required by ARS 28-3165.
Applicant’s Signature
Date
B. Representative or Parent/Guardian Certification on behalf of Applicant
The Representative or Parent/Guardian must complete Section B.
Name of Representative or Parent/Guardian
Name of Applicant
Residence Address
City
State
ZIP Code
The representative or parent/guardian for the applicant must certify and sign the following section. I certify under penalty of perjury the
information submitted on behalf of the above applicant is true and correct. The applicant does live at my residence or receives services at the
location listed above. I understand that according to Arizona law, it is a crime to knowingly make any false statement relating to application
for a driver license or identification card.
Representative or Parent/Guardian Signature
Date