GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF MOTOR VEHICLES
P.O. Box 91980
Washington, DC 20090
Power of Attorney
I, ______________________________________________________ of___________________
First Name Middle Name Last Name Business Name (if applicable)
located at __________________________ ________________________ _________ ________________________
Address City State Zip Code
as Principal in matters before the Department of Motor Vehicles (“DMV”), Adjudication Services, as
identified below do hereby
Name of Representative
as my true and lawful atto rney-in-fact to represent me/the company before Adjudication Services, with the power to
enter pleas and make full settlement and adjustment on any and all of my liabilities. Any final determination of
liability by Adju dication Services shall be binding ag ainst me/the company.
The Power of Attorney form is applicable for
all tickets/ the following specific tickets only:
1. The representative named above does not have to be an attorney. However, the hearing examiner has the
discretion to accep t or reject a representative who is not an attorney.
2. If the Power of Attorney is rescinded, please forward a copy to Adjudication Services at the address above.
3. If the Power of Attorney form is extended to all tickets, then it shall be valid for one year from the date
below, or until the Principal rescinds the Power of Attorney form, whichever comes first.
Signature of Principal
On__________ ________________________ _____, before me, the under signed, a Notary Public in and for said
State, person ally appeared______________________________________, personally known to me or proved to me
Name of Principal
on the basis of satisfactory evidence to be the person whose name is subscribed on this document as Principal and
acknowledged that he/she executed the same.
Witness my hand and official seal:
Notary Public in and for said State
It is unlawful to use a fictitious name or address and/or knowingly make any false statement on this application (D .C. Official Code §22-2405).
To report waste, fraud and abuse by any DC Government agency or official, call the DC Inspector General at 1-800-521-1639.
AD-PA-01 Rev. 07/05