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Get NY MV-104 2011-2022

Iod From 29 To Name and Address of Permit Holder If Self-Insured, give Certificate No. 30 and State Signature of Driver (or Representative*) of Vehicle 1 Print Name of Driver (or Representative*) of Vehicle 1 A representative may sign for the driver if the driver is unable to sign because of injury or death. If you are signing as the driver’s representative, check the box that describes why the driver cannot sign. * 3 Sex 4 City or Town Damaged Property ‘ Identify Other Than Vehi.

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