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Fillable Printable Safety Responsibility Security Deposit Disposition Affidavit

Fillable Printable Safety Responsibility Security Deposit Disposition Affidavit

Safety Responsibility Security Deposit Disposition Affidavit

Safety Responsibility Security Deposit Disposition Affidavit

STATE OF NORTH CAROLINA
DEPARTMENTOFTRANSPORTATION
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
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: _________________________
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