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 INSURANCE CANCELLATION DATE INSURANCE COMPANY TAG NUMBER TITLE NUMBER VEHICLE IDENTIFICATION NUMBER: YEAR: MAKE: VEHICLE OWNER (First, Last Name): OWNER'S DRIVERS LICENSE NUMBER: 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 MM/DD/YY . 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 # I certify, under penalty of perjury, that the statements made above by the vehicle owner are true and correct to the best of my knowledge, information and belief, under Section 12-109(b) of the Maryland Vehicle Law. Signature Witness Drivers License Number Date Daytime Phone Number Witness B I certify, under penalty of perjury, that the statements made above by the vehicle owner are true and correct to the best of my knowledge, information and belief, under Section 12-109(b) of the Maryland Vehicle Law. Witness Signature Drivers License Number Date Daytime Phone Number MVA Use Only Moving Violation/Accident Prior Case: Adjustment Approved: No q No q No q Yes q Yes q Yes q Date:_______________ Date:_______________ Amount: ____________ ID: _________________ Date:__________________ Case/Ticket #: _______________ Case #: _____________________ Authorized By: ________________________________________ For more information, please call: 410-768-7000 (to speak with a customer agent). TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov American LegalNet, Inc. www.FormsWorkFlow.com