Fillable Printable Installment Contract Form - Nebraska
Fillable Printable Installment Contract Form - Nebraska
Installment Contract Form - Nebraska
INSTALLMENT AGREEMENT FORM
(ACCIDENT / DEFAULT IN PAYMENT SUSPENSIONS ONLY)
SUSPENDED DRIVER’S PERSONAL INFORMATION (Please Print):
Last Name First Name Middle Initial Suffix (Jr., Sr., 2
nd
, 3
rd
)
Current Mailing Address Required (Street or PO Box) City State Zip Code
DATE OF BIRTH DRIVER’S LICENSE NUMBER SOCI AL SECURITY NUMBER (OPTIONAL)
Month Day Year
DATE OF LOSS / ACCIDEN T LOC ATION OF LOSS / ACCIDENT
Month Day Year
TERMS OF THE AGREEMENT:
Agreement covers the following (check [√] applicable below):
(√)
Property damages for:
Name Address
(√)
Personal injury for:
Name Address
**Medical payments pending (if applicable) for:
Name
Total dollar amount due or financed:
$
Frequency of payments (√ applicable):
Weekly:
(√)
Monthly:
(√)
Yearly:
(√)
Dollar amount of each payment: $
Date of first payment:
Month Day Year
SIGNATURES BELOW MUST BE EITHER WITNESSED OR NOTARIZED:
Suspended Driver’s Signature: Other Party (individual, insurance company, attorney, etc.) Signature:
Title of Position (for insurance company, attorney, etc.): Mailing Address:
Signing on behalf of (for insurance company, attorney, subrogee of , etc.):
Witness Signature (Must be a non-interested party):
Date:
Witness Signature (Must be a non-interested party):
Date:
Notary:
State of ________________________
County of ______________________
The foregoing instrument was acknowledged before me this
______ day of _________________, 20_____ by:
________________________________________
Name of suspended driver
Notary:
State of ________________________
County of ______________________
The foregoing instrument was acknowledged before me this
_______ day of __________________, 20_____ by:
__________________________________________
Name of other party or representative
↑Affix seal here↑
______________________________
Notary Public Signature ↑Affix seal here↑
________________________________
Notary Public Signature
**If medical payments are pending at time Installment Agreement is signed, you will be required to provide an
updated Installment Agreement form once the dollar amount is agreed upon.
Note: Installment Agreement is VOID unless all signatures are either witnessed or notarized.
Neb. Rev. Stat. 60-510(4)
- OVER / NEXT PAGE-
In the event of nonpayment or default on this Installment Agreement, the individual or company
accepting payments will immediately advise the Department of Motor Vehicles of such default and the
Financial Responsibility Division will proceed with the suspension of the operating privileges as
specified in §§60-511(4).
Forward this form along with the other reinstatement requirements (if applicable) to the Departme nt of
Motor Vehicles, Financial Responsibility Division, P.O. Box 94877, Lincoln, Nebraska 68509-
4877.
Upon receipt of the final payment, you will need to forward a RELEASE to the Department of Motor
Vehicles, Financial Responsibility Division, P.O. Box 94877, Lin coln, Nebraska 68509-4877.
Return completed agreement to:
Department of Motor Vehicles
Financial Responsibility Division
P.O. Box 94877
Lincoln, Nebraska 68509-4877
Phone: (402) 471-3985
Office Hours: 8:00 a.m. – 5:00 p.m. CST
Fax: (402) 471-8288
DMV Web Site: http://www.dmv.state.ne.us/
Printed on recycled paper
REV 02/2006
