Fillable Printable Safety Responsibility Security Deposit Disposition Affidavit

Safety Responsibility Security Deposit Disposition Affidavit

STATE OF NORTH CAROLINA

DEPARTMENT OF TRANSPORTATION

ROY COOPER

JAMES H. TROGDON, III

GOVERNOR

SECRETARY

Mailing Address:

NC DIVISION OF MOTOR VEHICLES

SAFETY RESPONSIBILITY UNIT

3108 MAIL SERVICE CENTER

RALEIGH, NC 27699

Telephone: (919) 861-3099

Fax: (919) 861-3091

Customer Service: 919-715-7000

Website: www.ncdot.gov

Location:

1100 NEW BERN AVENUE

RALEIGH, NC 27697

CUSTOMER NO: ____________________

ACCIDENT CASE NO: _______________

ACCIDENT DATE: __________________

ACCIDENT PLACE: _________________

SAFETY RESPONSIBILITY SECURITY DEPOSIT DISPOSITION AFFIDAVIT

I, __________________________, remit to NC Division of Motor Vehicles a security deposit

in the amount of $____________ in the form of a money order, cashier check.

(Please circle one)

I hereby certify that these funds shall be applied on my behalf and on the behalf of

_______________________________________________.

Additional person(s)

(If none, please write “no one else”)

Print Name: _____________________ Address: ________________________

________________________

Signature: _______________________ Date: _________________________