Motor Vehicle Administration
6601 Ritchie Highway, N.E.
Glen Burnie, Maryland 21062
Maryland Vehicle Insurance Compliance Program – Certified Statement
Section 1: Owner’s Information and Statement of Facts
INSURANCE CANCELLATION DATE
VEHICLE IDENTIFICATION NUMBER:
VEHICLE OWNER (First, Last Name):
OWNER’S DRIVERS LICENSE NUMBER:
The vehicle listed above has not been driven, involved in an accident, or issued a citation during period of insurance lapse
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to |
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. During this time the vehicle was parked at |
MM/DD/YY |
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MM/DD/YY |
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(Location)
(Street Address) |
(CIty) |
(State) |
(Zip Code) |
For the following reason(s):
(Supporting documentation attached)
I certify, under penalty of perjury, that the statements made above are true and correct to the best of my knowledge, information and belief, under Section 12-109 b (2) of the Maryland Vehicle Law.
Signature Owner/Co-Owner |
Date |
Daytime Telephone Number |
Section 2: Witness Statement of Facts
Witness A or Repair Facility - Business License #
I certify, under penalty of perjury, that the statements made above by the vehicle owner are true and correct to the best of my knowledge, information and belief, under Section 12-109(b) of the Maryland Vehicle Law.
Signature Witness |
Drivers License Number |
Date |
Daytime Phone Number |
Witness B
I certify, under penalty of perjury, that the statements made above by the vehicle owner are true and correct to the best of my knowledge, information and belief, under Section 12-109(b) of the Maryland Vehicle Law.
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Witness Signature |
Drivers License Number |
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Date |
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Daytime Phone Number |
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MVA Use Only |
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Moving Violation/Accident |
No q |
Yes q |
Date:_______________ |
Case/Ticket #:________________ |
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Prior Case: |
No q |
Yes q |
Date:_______________ |
Case #:______________________ |
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Adjustment Approved: |
No q |
Yes q |
Amount:_____________ |
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Authorized By:_ ________________________________________ |
ID:_ _________________ |
Date:__________________ |
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For more information, please call: 410-768-7000 (to speak with a customer agent).
TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov