AOC- 492.A Doc. Code: AFHD Rev. 5-16 Page 1 of 2 Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 189A.400-.460 COMMONWEALTH OF KENTUCKY VS. COM M O NW E A LT H O F K E lex et justitia Case No. ____________________ Court County Division ____________________ ____________________ ____________________ NT U C KY RT OF JUS TI Affidavit For Hardship License C _______________________________________________ The undersigned Affiant is the [ ] employer/self employed, [ ] educator, [ ] physician, or [ ] ADE program director for the above-named Defendant. Pursuant to KRS 189A.410 (see page 2), the undersigned states under oath that the above-named Defendant should be granted a hardship driver's license for the reason(s) stated below, including the specific days and times when the Defendant is required to drive. _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ If Employer/self-employed please provide the following information: Affiant's Business/Employer's name and address, Affiant's title, Affiant's phone number on page 2. Driving is necessary on the following days and at these specified times: From: Mon. Tues. Wed. Fri. Sat. Sun. ______________________ m. ______________________ m. ______________________ m. ______________________ m. ______________________ m. ______________________ m. To: ____________________ m. ____________________ m. ____________________ m. ____________________ m. ____________________ m. ____________________ m. ____________________ m. CO U E PLAINTIFF DEFENDANT Thurs. ______________________ m. WHEREFORE, Affiant prays that the above-named Defendant's Application for Hardship Driver's License be granted. NOTICE: Pursuant to KRS 189A.440(3), knowingly assisting Defendant in making a false application statement is a Class A Misdemeanor and results in revocation of the person's operator's license for six (6) months. ___________________________________________ Affiant's Name (Please Print) ___________________________________________ Affiant's Signature Subscribed and sworn to before me by the Affiant, this ______ day of ______________________, 2_______. My commission expires: __________________, 2_______. ______________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com AOC-492.A Rev. 5-16 Page 2 of 2 If Employer/self-employed please provide the following information: Affiant's Business/Employer's Name _______________________________________________________________ Affiant's Business/Employer's Address _______________________________________________________________ _______________________________________________________________ Affiant's Title ____________________________________________________________________________________ Affiant's Phone ___________________________________ INFORMATION REQUIRED PURSUANT TO KRS 189A.410 FOR ISSUANCE OF HARDSHIP LICENSE 1. If the license is sought for employment purposes: A written, sworn statement from your employer detailing your job, hours of employment, and the necessity for you to use a motor vehicle either in work at the direction of your employer during work hours, or in travel to and from work. If you are self-employed, provide the described information together with a sworn and notarized statement attesting to the truth of the above information. 2. If the license is sought for education purposes: A written, sworn statement from the school or educational institution that you attend containing your class schedule, courses being taken, and necessity for you to use a motor vehicle in travel to and from school or other educational institution. A license for educational purposes shall not include participation in sports, social, extracurricular, fraternal or other noneducational activities. 3. If the license is sought for medical purposes: A written, sworn statement from a physician or other medical professional licensed (but not certified) under Kentucky laws, attesting to your normal hours of treatment, and the necessity to use a motor vehicle to travel to and from the treatment. 4. If the license is sought for alcohol or substance abuse education or treatment purposes: A written, sworn statement from the director of any alcohol or substance abuse education or treatment program as to the hours in which you are expected to participate in the program, the nature of the program, and the necessity for you to use a motor vehicle to travel to and from the program. 5. If the license is sought for court-ordered counseling or other programs: A copy of any court order relating to treatment, participation in driver improvement programs, or other terms and conditions ordered by the court relating to you which require you to use a motor vehicle in traveling to and from the court-ordered program. The court order must include the necessity for use of a motor vehicle. 6. A sworn statement must be signed by a notary public. American LegalNet, Inc. www.FormsWorkFlow.com