Fillable Printable Release Form for Property Damage/Injury
Fillable Printable Release Form for Property Damage/Injury
Release Form for Property Damage/Injury
HSMV 74014 (Revised 06/13)
Florida DHSMV Release Form for Property Damage/Injury
SUSPENDED DRIVER’S PERSONAL INFORMATION (Please Print):
Last Name First Name Middle
Initial
Suffix Social Security Number
Current Mailing Address City State Zip Code Date of Crash
Date of Birth (MM/DD/YY) Driver’s License Number Location of Crash
Financial Responsibility Case Number Date of Full Release
Terms of Release: I/We do hereby release and forever discharge the party named above, from any and all claims and demands for damage,
injury or loss, arising out of the above listed crash. This release includes all future and unforeseen and unanticipated injuries, damages, loss
and liability, as well as those now known to exist. It is further agreed that this payment is not an admission of any liability.
Signatures Below Must Be Notarized: (Other party or representatives to other party choose applicable option below)
1.
Other Party Name (print):
Signature:
2. Signing on behalf of name (for insurance company, attorney, subrogee
of, etc.):
Signature:
Title of Position (for insurance company, attorney, etc.):
Notary Name: Name of other party or representative:
State of:
County of:
The foregoing instrument was acknowledged before me this ______ day of ______________________, 20____
by__________________, who is personally known to me or who produced a/an __________________ as identification and who
did (did not) take an oath.
Affix seal here Notary Public Signature:
Note: Release is VOID unless all signatures are notarized. Please retain a copy of this completed form for your
records.
Return to:
Department of Highway Safety and Motor Vehicles Phone: 850-617-2000
Bureau of Motorist Compliance, MS 98 Fax: 850-617-5216
Post Office Box 5775
Tallahassee, Florida 32314-5775 DHSMV Web Site: http//www.flhsmv.gov
Instructions
for completing the Agreement for Release and Monthly
Repayment Note:
1.
Make copies of this form and mail one to each releaser on your
list. Use certified mail, Return Receipt Requested.
If releaser signs and returns form to you, take the signed releases and your original SR22 form
to your nearest Florida driver’s license office or mail to the address on the front of this letter.
If releaser refuses to sign forms or does not respond to your mailing, you must pay the
security deposit associated with that person. Deposits are held for one year from date of deposit.
After 11 months from the date of deposit, if unclaimed, you will be mailed a letter to your address
on record with instructions on how to claim your deposit. You must complete and return the
request for the deposit to be refunded one year after, but no more than five years, from the date of
deposit. When you pay your security deposit at your local office, you will need to bring any
signed releases and your original SR22 form or mail them to the address on the front of this letter.
If mailing is returned to you undeliverable, take the sealed envelope to your local office to
have the releaser amount reduced to $100.00 for bodily injury and/or $250.00 for property
damage. When you pay your reduced security deposit at your local office, you will need to bring
any signed releases and your original SR22 form.
2. Keep a copy of each Agreement for Release and Monthly
Repayment Note for your records.
Return to: Department of Highway safety and Motor Vehicles Phone: 850‐617‐2000
Bureau of Motorist Compliance, MS 98 Fax: 850‐617‐5216
Post Office Box 5775
Tallahassee, Florida 32314‐5775
DHSMV Web Site: http//www.flhsmv.gov
