Dps Form Sr-19 - Installment Agreement - Texas
ADVERTISEMENT
1TO:
DEPARTMENT OF PUBLIC SAFETY
SAFETY RESPONSIBILITY
PO BOX 15999
AUSTIN, TX 78761-5999
Accident Case No. ______________________
INSTALLMENT AGREEMENT
As a result of a motor vehicle accident which occurred at _________________________________, Texas, on
___________________________________
__________,
the
undersigned,
hereafter
known
as
party
of
(Year)
the first part, does hereby agree to effect settlement of claims for damages and/or personal injuries suffered by
_________________________________________________________________________________________________
hereafter known as the party of the second part, on the following terms:
The party of the first part agrees to pay the sum of ________________________________________)
($ ______________________ ) to the party of the second part or to his/her personal representative at
the rate of $ ________________________ or more per _________________________, first payment
$ ______________________________ due __________________________________, ________.
(Year)
Upon compliance with the provisions of this agreement the party of the second part shall deliver to the
party of the first part a complete and unconditional release from all claims and causes of action he/she
now has or hereafter may have against the party of the first part on account of damages and/or
personal injuries resulting from the accident referred to.
STATE OF TEXAS _____________________________ )
Dated ____________________________, _________.
ss.
(Year)
COUNTY OF __________________________________ )
___________________________________________
(Party of the First Part)
TDL # ______________________________________
_____________________________________________________, party of the first part, personally appeared before me,
a Notary Public in and for said County, and acknowledged the execution of the above agreement.
My commission expires:
___________________________________________
(Notary Public)
_______________________________________
ACCEPTANCE
I accept the foregoing agreement and acknowledge that I will execute a release in behalf of the party of the first part upon
completion of its terms.
STATE OF _________________________________ )
Dated ___________________________, _________.
(Year)
ss.
COUNTY OF _______________________________ )
__________________________________________
(Party of the Second Part)
__________________________________________________, party of the second part, personally appeared before me,
a Notary Public in and for said County, and acknowledged the acceptance of the above agreement.
My commission expires:
__________________________________________
(Notary Public)
______________________________________
IF FORM SR-19 IS FILED AFTER THE DRIVER LICENSE IS SUSPENDED,
A $100.00 REINSTATEMENT FEE WILL BE REQUIRED TO COMPLETE COMPLIANCE.
SR-19 (Rev. 9/99)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal