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Financial Security Exemption Application FS-48 - New York

Financial Security Exemption Application Form. This is a New York form and can be used in Department Of Motor Vehicles Statewide .
 Fillable pdf Last Modified 9/19/2011
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FS-48 (11/10) New York State Department of Motor Vehicles FINANCIAL SECURITY EXEMPTION APPLICATION This document is an application for exemption from the Financial Security Law (as defined in section 318 of the NYS Vehicle and Traffic Law). This application is to be completed by appropriate facility staff and signed by the facility manager or owner as well as by the registrant. A copy of the repair shop invoice, as well as evidence that the vehicle is currently in compliance with the financial security sections of the Vehicle and Traffic Law, must accompany your application. Compliance may take the form of a current NYS insurance card, plate surrender, a report of lost or stolen plates (MV-78B), or the expiration of your vehicle registration. Please be aware that coverage will be confirmed with your insurance carrier. If this exemption involves multiple facilities or invoices, separate applications must be completed. Send original application and compliance documentation to NYS DMV, Insurance Services Bureau, 6 Empire State Plaza, Albany, NY 12228. EXEMPTION TYPE REQUESTED: oRepair Shop A. FACILITY INFORMATION Facility Name Address Telephone Number NYS Facility Registration Number o Junk/Salvage ( ) Facility License Expiration Date B. VEHICLE/REGISTRANT INFORMATION Registrant Name Address License Plate # Vehicle Year and Make VIN C. ACTIVITY DATES Date vehicle entered facility: _____________________ Is the vehicle still in the facility's possession? o YES o NO If not, when was vehicle released to the motorist? __________________ Was this vehicle involved in any motor vehicle accidents, Vehicle and Traffic Law violations or parking violations during the period in question? o YES o NO If "yes", please provide an explanation below: A FALSE STATEMENT ON THIS APPLICATION MAY BE PUNISHABLE AS A CRIME UNDER THE NEW YORK STATE PENAL LAW. Print Registrant's Name ________________________________________________________ Signature ç ___________________________________________________________ Date _______________________ FALSE STATEMENTS ON THIS APPLICATION ARE PUNISHABLE BY LAW AND MAY RESULT IN THE SUSPENSION OR REVOCATION OF YOUR BUSINESS CERTIFICATE(S). THE PERSON SIGNING THIS APPLICATION STATES THAT SHE OR HE IS THE OWNER OR MANAGER OF THE FACILITY NAMED ON THIS APPLICATION AND THAT ALL INFORMATION PROVIDED IS TRUE. Print Name of Facility Owner/Manager ________________________________________________________ Signature ç ___________________________________________________________ All Documentation is Subject to Review and Approval. American LegalNet, Inc. www.FormsWorkFlow.com Date _______________________
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