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Get CT DMV Affidavit

Y operate a motor vehicle, the following Affidavit must be completed in its entirety and returned to the address noted below. I, , being duly sworn, have serious concerns about the ability of: (Print your name) Name: Date of Birth: (Print name) Address: (City) (Zip Code) (State) to safely operate a motor vehicle, due to his/her medical condition. This Affidavit is based upon my personal observation and is made under oath and subject to penalty of false statement. Briefly describe the inci.

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