Insurance Services Bureau
6 Empire State Plaza
Albany New York 12228-0330
Section 332 of the Vehicle and Traffic Law authorizes the Commissioner of Motor Vehicles to suspend the driver license and
registration privileges of any person (or company) who fails to pay a judgment of more than $1,000 that results from the use or
operation of any motor vehicle.
If you or your client obtain a judgment (or have already obtained a judgment), that you believe will qualify, please complete, sign
and return this affirmation with the following documents:
l a copy of the outstanding judgment, with ORIGINAL court or attorney certification.
l a copy of the complaint and summons.
l a copy of any available police accident report (MV-104A) or motorist accident report (MV-104).
WE WILL CONTACT YOU TO TELL YOU ABOUT ANY SUSPENSION ACTION OR OTHER ACTIVITY IN THIS CASE.
1. Judgment debtor’s name _____________________________________________ Date of birth____________________
License ID number ____________________________________________________________________________________
License plate number_________________________________
2. Date of occurrence ______________________________________
3. Has the judgment debtor appealed the judgment? ............
o Yes o No
4. Has the time to appeal the judgment expired? .................. o Yes o No
5. Are any appeals pending? ................................................ o Yes o No
6. Amount now actually due on the judgment $ ________________________
AFFIRMATION TO BE COMPLETED
I affirm under the penalties of perjury that the above information is true and correct. False statements made in this document are
punishable under Section 210.45 of the Penal Law.
ç __________________________________________________________ Date __________________________
Send this affirmation and all requested documents to the Insurance Services Bureau at the address shown at the top of the page.