Get MD ICD-071 2013-2024

Motor Vehicle Administration 6601 Ritchie Highway N.E. Glen Burnie Maryland 21062 ICD-071 12-13 Maryland Vehicle Insurance Compliance Program Certified Statement Section 1 Owner s Information and Statement of Facts CASE NUMBER TAG NUMBER INSURANCE CANCELLATION DATE TITLE NUMBER INSURANCE COMPANY VEHICLE IDENTIFICATION NUMBER YEAR MAKE OWNER S DRIVERS LICENSE NUMBER VEHICLE OWNER First Last Name The vehicle listed above has not been driven involved in an accident or issued a citation during period of insurance lapse MM/DD/YY to. During this time the vehicle was parked at Location Street Address CIty State Zip Code For the following reason s Supporting documentation attached I certify under penalty of perjury that the statements made above are true and correct to the best of my knowledge information and belief under Section 12-109 b 2 of the Maryland Vehicle Law. Signature Owner/Co-Owner Date Daytime Telephone Number Section 2 Witness Statement of Facts Witness A or Repair Facility - Business License best of my knowledge information and belief under Section 12-109 b of the Maryland Vehicle Law. Signature Witness Drivers License Number Daytime Phone Number Witness B Witness Signature MVA Use Only Moving Violation/Accident No q Yes q Date Case/Ticket Prior Case Case Adjustment Approved No q Yes q Amount Authorized By ID Date For more information please call 410-768-7000 to speak with a customer agent. During this time the vehicle was parked at Location Street Address CIty State Zip Code For the following reason s Supporting documentation attached I certify under penalty of perjury that the statements made above are true and correct to the best of my knowledge information and belief under Section 12-109 b 2 of the Maryland Vehicle Law. Signature Owner/Co-Owner Date Daytime Telephone Number Section 2 Witness Statement of Facts Witness A or Repair Facility - Business License best of my knowledge information and belief under Section 12-109 b of the Maryland Vehicle Law. Signature Owner/Co-Owner Date Daytime Telephone Number Section 2 Witness Statement of Facts Witness A or Repair Facility - Business License best of my knowledge information and belief under Section 12-109 b of the Maryland Vehicle Law. Signature Witness Drivers License Number Daytime Phone Number Witness B Witness Signature MVA Use Only Moving Violation/Accident No q Yes q Date Case/Ticket Prior Case Case Adjustment Approved No q Yes q Amount Authorized By ID Date For more information please call 410-768-7000 to speak with a customer agent. During this time the vehicle was parked at Location Street Address CIty State Zip Code For the following reason s Supporting documentation attached I certify under penalty of perjury that the statements made above are true and correct to the best of my knowledge information and belief under Section 12-109 b 2 of the Maryland Vehicle Law. Signature Owner/Co-Owner Date Daytime Telephone Number Section 2 Witness Statement of Facts Witness A or Repair Facility - Business License best of my knowledge information and belief under Section 12-109 b of the Maryland Vehicle Law. Signature Witness Drivers License Number Daytime Phone Number Witness B Witness Signature MVA Use Only Moving Violation/Accident No q Yes q Date Case/Ticket Prior Case Case Adjustment Approved No q Yes q Amount Authorized By ID Date For more information please call 410-768-7000 to speak with a customer agent. .