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Get IL DSD FR 9 2005

THIS FORM MUST BE MAILED SEPARATELY TO THE ADDRESS BELOW. OUT-OF-STATE AFFIDAVIT FINANCIAL RESPONSIBILITY INSURANCE WAIVER Former Illinois Driver s License Number New Driver s License Number if applicable Full Name Last First Current Street Address City Prior Illinois Street Address Middle Sex Date of Birth Male State Day Year County ZIP Month Social Security Number Female I hereby affirm that I am no longer a resident of the State of Illinois and I am requesting that I be relieved of the requirement to file Proof of Financial Responsibility in Illinois as outlined in Public Act 94-0224. Signature Date Once this request has been processed and accepted you will be notified in writing. Please allow ample time for processing. If you return to Illinois in the next three years you will be required to file proof of insurance in the form of an SR22 Certificate before issuance of a new Illinois driver s license. AND MAILED DIRECTLY TO THE FOLLOWING ADDRESS Illinois Secretary of State Driver Services Department Financial Responsibility Section 2701 S. Dirksen Pkwy. THIS FORM MUST BE MAILED SEPARATELY TO THE ADDRESS BELOW* OUT-OF-STATE AFFIDAVIT FINANCIAL RESPONSIBILITY INSURANCE WAIVER Former Illinois Driver s License Number New Driver s License Number if applicable Full Name Last First Current Street Address City Prior Illinois Street Address Middle Sex Date of Birth Male State Day Year County ZIP Month Social Security Number Female I hereby affirm that I am no longer a resident of the State of Illinois and I am requesting that I be relieved of the requirement to file Proof of Financial Responsibility in Illinois as outlined in Public Act 94-0224. Signature Date Once this request has been processed and accepted you will be notified in writing. Please allow ample time for processing* If you return to Illinois in the next three years you will be required to file proof of insurance in the form of an SR22 Certificate before issuance of a new Illinois driver s license. AND MAILED DIRECTLY TO THE FOLLOWING ADDRESS Illinois Secretary of State Driver Services Department Financial Responsibility Section 2701 S* Dirksen Pkwy. Springfield IL 62723 Phone 217-782-3720 Printed by authority of the State of Illinois. December 2005 10M DSD FR 9. Signature Date Once this request has been processed and accepted you will be notified in writing. Please allow ample time for processing* If you return to Illinois in the next three years you will be required to file proof of insurance in the form of an SR22 Certificate before issuance of a new Illinois driver s license. AND MAILED DIRECTLY TO THE FOLLOWING ADDRESS Illinois Secretary of State Driver Services Department Financial Responsibility Section 2701 S* Dirksen Pkwy. AND MAILED DIRECTLY TO THE FOLLOWING ADDRESS Illinois Secretary of State Driver Services Department Financial Responsibility Section 2701 S* Dirksen Pkwy. Springfield IL 62723 Phone 217-782-3720 Printed by authority of the State of Illinois. December 2005 10M DSD FR 9. .

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