Form 465 - Settlement Agreement And Release Division Of Motor Vehicles State Of Alaska
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1STATE OF ALASKA
DIVISION OF MOTOR VEHICLES
SETTLEMENT AGREEMENT AND RELEASE
CRASH
INFORMATION
Crash Date:
Location:
Printed Name: ____________________________________________________________________________________
INVOLVED
PARTIES
Printed Name: ____________________________________________________________________________________
Amount of Settlement: ________________ Amount Received as of This Date: ____________________
TERMS OF
AGREEMENT
Payment Due Each Month By: __________ Amount of Monthly Payment: _________________________
Whereas the involved parties listed above were involved in a motor vehicle crash, and it is desired on the part of both
parties that a settlement be reached.
IT IS ACCORDINGLY AGREED AND STIPULATED by and between the parties as follows:
agrees to pay and
agrees to accept the terms of the agreement as set forth above until the balance is paid in full.
IT IS FURTHER AGREED that upon the payment of the amount agreed upon,
will be entitled to be forever released in full and to the complete satisfaction of this claim.
FURTHER, that in the case of the failure of
to make any one of the payments agreed upon,
shall have the right to proceed by any action prescribed by law to have and recover the full amount less credits of
payments, or in the alternative to sue for such damages as may have been sustained as a result of the crash.
IT IS FURTHER AGREED that this document be filed with the Division of Motor Vehicles (DMV), for the State of Alaska,
in compliance with the Financial Responsibility Law, and if there is any default in the payment of any installment, notice
of such default will be furnished to the DMV / PO Box 110221 / Juneau, Alaska 99811-0221.
NOTARY or DMV REPRESENTATIVE WITNESS REQUIRED:
(SEAL)
/
/
20
Signature of Person Giving Release
Date
After printing the
form, please check
/
/
20
the information
Signature of Person Accepting Terms of Settlement
Date
carefully and sign
the form in front of a
,
20
Subscribed And Sworn To Before Me This
day of
Month
Year
Notary.
Notary or Alaska DMV Representative (AMVC & Office Location)
My Commission Expires
DMV USE ONLY:
SR#:
OLN:
DOA:
Alaska.gov/dmv
laska.gov
E-mail: DOA.DMV.JDL@A
Form 465 (Rev. 10/2009)
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