Form MV-44DRF - Resident Disaster Victims Relief Supplemental Information and Attestation - New York

New York State Department of Motor Vehicles
NYS RESIDENT DISASTER VICTIMS RELIEF
SUPPLEMENTAL INFORMATION AND ATTESTATION
I certify that I am a New York State resident of one of the counties listed below. I am applying for a replacement driver
permit, driver license, non-driver identification card, certificate of registration, license plate(s), and/or certificate of title
that have been damaged or lost as a result of a disaster.
Effective Friday, November 9, 2012, these replacement documents will be issued at no charge.
PLEASE COMPLETE THE INFORMATION BELOW
Last Name
Date of Birth (Month/Day/Year)
First Name Middle Name
/ /
Street # and Name
Telephone Number: E-Mail Address
I am applying for a replacement: (check all that apply)
Apt. # City/Town Zip Code State County
Current New York State Address:
ATTESTATION
( )
¨ Permit, Class __________
¨ Driver License, Class __________
¨ Non-Driver Identification Card
¨ Certificate of Registration
¨ License Plate(s)
¨ Certificate of Title
Sign Here ç
Date:
MV-44DR-F (11/12)
New York
Queens
Richmond
Rockland
Suffolk
Westchester
Bronx
Kings
Nassau
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Form MV-44DRF - Resident Disaster Victims Relief Supplemental Information and Attestation - New York PDF

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