Fillable Printable Form FS-48 - Financial Security Exemption Application - New York

Form FS-48 - Financial Security Exemption Application - New York

FINANCIAL SECURITY EXEMPTION APPLICATION

This document is an application for exemption from the Financial Security Law (as defined in section 318 of the NYS Vehicle

and Traffic Law). This application is to be completed by appropriate facility staff and signed by the facility manager or owner

as well as by the registrant. A copy of the repair shop invoice, as well as evidence that the vehicle is currently in compliance

with the financial security sections of the Vehicle and Traffic Law, must accompany your application. Compliance may take

the form of a current NYS insurance card, plate surrender, a report of lost or stolen plates (MV-78B), or the expiration of your

vehicle registration. Please be aware that coverage will be confirmed with your insurance carrier. If this exemption involves

multiple facilities or invoices, separate applications must be completed. Send original application and compliance

documentation to NYS DMV, Insurance Services Bureau, 6 Empire State Plaza, Albany, NY 12228.

FS-48 (7/15)

EXEMPTION TYPE REQUESTED: oRepair Shop o Junk/Salvage

A. FACILITY INFORMATION

Facility

Name

Address

Telephone Number

( )

NYS Facility

Registration

Number

Facility License

Expiration

Date

B. VEHICLE/REGISTRANT INFORMATION

Registrant

Name

Address

License Plate # Vehicle Year and Make VIN

C. ACTIVITY DATES

Date vehicle entered facility: _____________________

Is the vehicle still in the facility’s possession?

o YES o NO

If not, when was vehicle released to the motorist? __________________

Was this vehicle involved in any motor vehicle accidents, Vehicle and Traffic Law violations or parking violations during the

period in question?

If “yes”, please provide an explanation below:

o YES o NO

A FALSE STATEMENT ON THIS APPLICATION MAY BE PUNISHABLE AS A CRIME UNDER THE NEW YORK STATE

PENAL LAW.

Print Registrant’s Name ________________________________________________________

Signature ç ___________________________________________________________

Date _______________________

FALSE STATEMENTS ON THIS APPLICATION ARE PUNISHABLE BY LAW AND MAY RESULT IN THE SUSPENSION OR

REVOCATION OF YOUR BUSINESS CERTIFICATE(S). THE PERSON SIGNING THIS APPLICATION STATES THAT SHE

OR HE IS THE OWNER OR MANAGER OF THE FACILITY NAMED ON THIS APPLICATION AND THAT ALL INFORMATION

PROVIDED IS TRUE.

Print Name of Facility Owner/Manager ________________________________________________________

Signature ç ___________________________________________________________

Date _______________________

All Documentation is Subject to Review and Approval.

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