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

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

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

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

FINANCIALSECURITYEXEMPTIONAPPLICATION
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 oJunk/Salvage
A. FACILITYINFORMATION
Facility
Name
Address
Telephone Number
( )
NYS Facility
Registration
Number
Facility License
Expiration
Date
B. VEHICLE/REGISTRANTINFORMATION
Registrant
Name
Address
License Plate #Vehicle Year and MakeVIN
C. ACTIVITYDATES
Date vehicle entered facility: _____________________
Is the vehicle still in the facility’s possession?
oYES oNO
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:
oYES oNO
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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