New York State Department of Motor Vehicles STATEMENT OF IDENTITY AND/OR RESIDENCE For Applicants Represented by Government or Government-Approved Facilities This document is used for Identity and/or Residence Only and cannot be used for Proof of Date of Birth. Proof of Date of Birth and a Social Security card are required. This statement may only be used by an applicant who is mentally or physically challenged, is represented by a Government or GovernmentApproved facility, AND who cannot provide sufficient proof of: ä Identity from the proofs listed on form ID-44 (Proofs of Identity); and/or ä Residence from the proofs listed on form ID-44EDL (Proofs of Identity, Citizenship and Residence). Please note: one additional proof of residence must accompany this statement. Proof of residence is only required when applying for an enhanced document. The applicant and his or her approved facility representative may use the following method for PROOF OF NAME AND/OR RESIDENCE: ä The approved representative must accompany the applicant when he or she applies for a permit/ID card and must sign this form in the presence of a Motor Vehicle Representative. ä The applicant’s representative must be a government or government-approved facility representative, and must provide his/her original facility ID card/document along with a letter on the facility’s letterhead, signed by the representative’s supervisor. This letter must verify the applicant’s name, date of birth, address, height, eye color, the name of the facility and the name of the representative. If the letter is submitted from a government-approved facility, the letter must indicate the name of the NYS facility and the facility’s certificate number. ä The representative must have a valid New York State Photo Driver License/Permit/or Non-Driver Identification Card, and must show this proof along with the above documents at the time of application. CERTIFICATION I, ___________________________________________________________________________________, certify as the Representative (Name of Representative) of ______________________________________________________________________________________________, who resides at (Name of Applicant) _____________________________________________________________________________________________________________ (Applicant’s Address) that this name is the name by which (s)he is commonly known and that (s)he resides at the address above. To the best of my knowledge, (s)he has not obtained or applied for a learner permit, non-driver identification card or driver license in any other name. I understand that any false statement I have made on this certification is a misdemeanor under Section 392 of the Vehicle & Traffic Law. This certification must be accompanied by an original letter from the government facility that has approved the applicant’s representative (see above). IMPORTANT: DO NOT SIGN THIS FORM UNTIL YOU ARE WITH A MOTOR VEHICLE REPRESENTATIVE. APPLICANT’S REPRESENTATIVE Sign Here ç _______________________________________________________ Print Your Name:________________________________________________________________________________________________ Identification No. from your Driver License, Permit or Non-Driver ID Card: _________________________________________________ Print Your Facility’s Name: Facility’s Phone No.: Facility’s Mailing Address: IMPORTANT: DO NOT SIGN THIS FORM UNTIL YOU ARE WITH A MOTOR VEHICLE REPRESENTATIVE. APPLICANT Sign Here ç _________________________________________________________ OFFICE USE ONLY Proofs of Identify Presented by Representative (all are required): o NYS Photo Driver License/Permit/Non-Driver ID o Government or Government-Approved Facility Letter o Government or Government-Approved Facility ID Card/document Signature of Person Accepting Proof ç ____________________________________________________________________ Title of Person Accepting Proof: ________________________________________________ Office: _______________________________________________________________ Date __________________________ MV-45A (4/11) www.dmv.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com