State Form 39531 - Agreement Of Financial Liability - Indiana


(To be used if applicant is under 18 years of age)
Notice: If the applicant is under the age of 18, the following statement
must be signed and sworn to or affirmed (before a person authorized to
administer oaths) by the father or mother or guardian having custody. In
the event neither parent is living within the state and the applicant has
no guardian, this statement may be signed by the person having custody
of the applicant or by an employer of said applicant and in the event
there is no parent, guardian, or employer, then by any other responsible
person willing to assume the obligations imposed by this statement.
_____________________________________________ (herein minor)
has applied for a driver license or a learner permit.
The undersigned AFFIANT hereby agrees to be responsible, jointly
and severally with the MINOR for any injury of damages which said
MINOR may cause, by reason of operation of a motor vehicle, in such
cases as the MINOR is found to be liable for such injuries or damages.
The assumption of liability by the AFFIANT shall terminate upon
t h e M I N O R ' S e i g h t e e n t h b i r t h d a y o r e m a n c i p a t i o n .
I swear or affirm that the information I have entered on this form is
correct. I understand that making a false statement on this form may
constitute the crime of perjury.
Name of affiant
Address of affiant
Relationship to applicant
Parent with custody
Person with custody
Guardian with custody
Other (specify) ____________________
COUNTY OF_______________________
Subscribed and sworn to before me this ____ day of __________________,
Signature of Notary Public
Date Commission expires
Printed or typed name of Notary Public
County of residence
State Form 39531 (R3 / 1-02)


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