Fillable Printable Form FS-15 - Affirmation Under Vehicle and Traffic Law - New York

Form FS-15 - Affirmation Under Vehicle and Traffic Law - New York

Insurance Services Bureau

6 Empire State Plaza

Albany NY 12228

www.dmv.ny.gov

AFFIRMATION UNDER SECTIONS 318(9) & 318(11)

OF THE NEW YORK VEHICLE AND TRAFFIC LAW

I, _______________________________________________, affirm under penalties of perjury that:

(1) I reside at ______________________________________________________________________________________

_______________________________________________________________________________________________

(Print Name in Full)

(Number, Street, Apartment No.)

(City)(State)(Zip Code)

(2) I was involved in an accident as the (check one or both) oowner ooperator of a motor vehicle on

_______________________ at __________________________________________________. At that time, I resided at

_______________________________________________________________________________________________

(3) There are no legal actions pending against me which were started within one year from the date of the accident by any

damaged party involved, nor are there any unsatisfied judgments outstanding against me resulting from any such legal

actions that have been resolved.

(4) One year has passed since I complied with the revocation order. I request that my driving privileges be restored.

ç __________________________________________________________ __________________ __________________

(Date of Accident)

(Number, Street, Apartment No.)

(City)(State)(Zip Code)

(Location of Accident)

(Signature - Sign Name in Full)(Date of Birth)(Date)

DMV Accident Revocation

Case # _____________________________ Date _________________________Order # __________________________

INSTRUCTIONS: Complete this form by filling in the blank spaces. Return it to the address at the top of this page.

This affirmation is not acceptable if completed before __________________________________.

FS-15 (7/15)

AFFIRMATION