Form Hsmv 72871 - Florida Highway Safety And Motor Vehicles

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NOTIFICATION TO THE DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
STUDENT COMPLIANCE WITH ENROLLMENT REQUIREMENTS
FOR A HOME EDUCATION PROGRAM
This is to provide verification to the Department of Highway Safety and Motor Vehicles that the
following student, who received Notice of Intent to Suspend/Withhold Eligibility for Licensure
due to non-attendance has been enrolled in a home based education program 30 consecutive
days.
Student’s Full Legal Name: ______________________________________________________
(First, Middle, Last)
Mailing Address: ______________________________________________________________
Driver License/Control Number: __________________________Gender: ____Male____Female
Date of Birth: _______/______/______ Social Security Number: _________________________
District Name: ___________________________ District Number: ________________________
School Name: ___________________________ School/Institution Number: ________________
Date: _______/_______/_______
Authorized Signature of School Official: ____________________________________________
(Signature must be notarized or school seal affixed)
Title: _________________________________________________________________________
Typed or Printed Name of Person Signing Form: ______________________________________
_________________________________________
Notary Public
State of Florida at Large
___________________________________ My commission expires: _______/_______/______
School Seal
Original signatures required.
_____________________________________________________________________________
For additional information contact:
Name________________________________________Telephone: _______________________
You may mail, fax or e-mail this completed form to: DHSMV, 2900 Apalachee Parkway, MS
#39, Tallahassee, Florida 32399-0570. The fax number is (850)-617-5095 and the e-mail
address is Truancy@flhsmv.gov. If the license is suspended, present this form to a driver
license or a tax collector’s office for reinstatement of your driving privilege. A $45
reinstatement fee is required for a suspended license.
Note: This form may only be accepted within 30 calendar days of its completion.
HSMV 72871 (07/15)

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