Fillable Agreement And Conditional Accident Release Form

MVID #______________________________

AGREEMENT AND CONDITIONAL

WY DL #______________________________

ACCIDENT RELEASE

Instructions:

Print clearly and legibly. Must be signed in the presence of a Driver License Examiner or Notary Public.

PART 1 (to be completed by person granting conditional release)

FOR AND IN CONSIDERATION OF $_________________ DOLLARS, payable under the terms of this agreement, I

_____________________________________, hereby release, _____________________________________, from all liability, claims for damages,

or any other claims arising out of or from the motor vehicle accident which occurred on the ___________ day of ___________________________,

20______, in ____________________ County, Wyoming.

HOWEVER, it is expressly understood and agreed that said release is conditional upon payment of installments, set forth herein, when due.

I hereby state that I have read this release, know the contents thereof and have signed same relying on my own judgment and on no representations

of others, and of my own free will and accord this _________ day of _____________________, 20_______.

SIGNATURE OF VEHICLE OWNER

SIGNATURE OF INJURED PARTY (if minor, a parent or guardian must

AND/OR

sign below)

PARENT OR LEGAL GUARDIAN

 FATHER

 MOTHER

 LEGAL GUARDIAN

SIGNATURE OF INSURANCE REPRESENTATIVE

(check one)

ON BEHALF OF (name of insured)

DRIVER LICENSE EXAMINER SIGNATURE

DATE

NOTARY PUBLIC

Subscribed and sworn to before me by __________________________________________

this ________ day of ____________________, 20 ______,

In the State of Wyoming, County of _____________________________________________

Signature of Notary Public ____________________________________________________

My Commission expires ________________________________

SEAL

PART 2 (to be completed by person being released)

For this release, I promise to pay ____________________________ the sum of $_________________ DOLLARS, payable in installments as follows:

_______________________________________________________________________________________________________________________

HOWEVER, it is expressly understood and agreed that said release is conditional upon payment of installments, set forth herein, when due. Failure to

pay any of said installments when due shall render the whole of said indebtedness due and payable at the option of the holder of this note.

I hereby state that I have read this release, know the contents thereof and have signed same relying on my own judgment and on no representations

of others, and of my own free will and accord this _________ day of _____________________, 20_______.

DATE OF BIRTH

PRINT NAME

SIGNATURE

DRIVER LICENSE EXAMINER SIGNATURE

DATE

NOTARY PUBLIC

Subscribed and sworn to before me by __________________________________________

this ________ day of ____________________, 20 ______,

In the State of Wyoming, County of _____________________________________________

Signature of Notary Public ____________________________________________________

My Commission expires ________________________________

SEAL

Should you have any questions regarding this form, please contact the Customer Service Desk at 307-777-4810.

Mail to: WYDOT - Driver Services, 5300 Bishop Boulevard, Cheyenne, WY 82009-3340 OR Fax to: 307-777-3823

Accident Release (05/29/14)

WYDOT – DRIVER SERVICES

Agreement And Conditional Accident Release Form - Wyoming

Related Articles

Related forms

Related Categories