Form Sr-11 - Release Form
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1TO:
DEPARTMENT OF PUBLIC SAFETY
IF FORM SR-11 IS FILED AFTER THE DRIVER LICENSE
SAFETY RESPONSIBILITY
IS SUSPENDED, A $100.00 REINSTATEMENT FEE WILL
PO BOX 15999
BE REQUIRED TO COMPLETE COMPLIANCE.
AUSTIN, TX 78761-5999
RELEASE
CASE NO. _______________________________________
THE UNDERSIGNED HEREBY CERTIFIES
that he/she is of the age of 18 years or over and that he/she has released
_________________________________________________________________________________________________
(Type or print name, address, date of birth, and driver's license number of person released.)
from all claims and causes of action or judgments arising from an accident which occurred on _______________, _____,
(Year)
at or near _______________________, Texas, and authorizes the Safety Responsibility Division of the Texas
Department of Public Safety to accept this certification as satisfactory evidence of such release from liability or satisfaction
of judgments as required by the Texas Motor Vehicle Safety Responsibility Act. (Texas Transportation Code, Section
601.162(a)(3)(A)).
Date __________________________________, __________
___________________________________________
(Year)
Signature of person giving release
Subscribed and sworn to before me this ____________________, day of _____________________________, ________
(Year)
___________________________________________
Notary Public in and for ______________________
County, Texas
RELEASE
CASE NO. _______________________________________
THE UNDERSIGNED HEREBY CERTIFIES
that he/she is of the age of 18 years or over and that he/she has released
_________________________________________________________________________________________________
(Type or print name, address, date of birth, and driver's license number of person released.)
from all claims and causes of action or judgments arising from an accident which occurred on _______________, _____,
(Year)
at or near _______________________, Texas, and authorizes the Safety Responsibility Division of the Texas
Department of Public Safety to accept this certification as satisfactory evidence of such release from liability or satisfaction
of judgments as required by the Texas Motor Vehicle Safety Responsibility Act. (Texas Transportation Code, Section
601.162(a)(3)(A)).
Date __________________________________, __________
___________________________________________
(Year)
Signature of person giving release
Subscribed and sworn to before me this ____________________, day of _____________________________, ________
(Year)
___________________________________________
Notary Public in and for ______________________
County, Texas
SR-11 (Rev. 9/99)
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