Form Mvl 17-Driver'S License/identification Card Residency Eligibility Affidavit Form
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2DRIVER’S LICENSE/IDENTIFICATION CARD RESIDENCY ELIGIBILITY AFFIDAVIT
I ____________________________________________, of ________________________________________________,
(Printed Name of Person Certifying Residency)
(Street Address of Person Certifying Residency)
in _____________________, ______ ________, certify that ________________________________________________
(City/Town)
(State)
(Zip Code)
(Printed Name of Applicant)
of ________________________________________ in __________________ physically resides in the State of Maine.
(Applicant’s Street Address)
(City/Town)
My mailing address is:
same as above, or: ___________________________________________________________.
(Check the box if same as above, or insert complete mailing address if different from physical address.)
Relationship to applicant:
Parent/Guardian;
Spouse;
Sibling;
Other: ________________________________
(Please State Relationship to Applicant)
Date of Birth: __________________; Telephone: home: _____________; cell: ______________; work: _____________.
This section is reserved for the sole use of an Agency or Organization in order to affirm the named individual’s
residence or domicile in Maine at the time the certification is completed. This form does not establish identity.
The applicant must provide separate identity documentation at time of application.
I _________________________________________, certify that ___________________________________________
(Printed Name of Representative Certifying Residency)
(Printed Name of Applicant)
is receiving services from the Agency/Organization named below and currently resides at the address indicated below.
_____________________________________________________________________________________________
is a homeless individual, that the name is the name by which (s)he is commonly known, and (s)he currently resides
at or receives services from the shelter address indicated below:
_____________________________________________________________________________________________
Printed Name of Agency or Organization Making Certification: ______________________________________________
Agency/Organization’s Address: ______________________________________________________________________
(Street Address)
(City/Town)
Agency’s Telephone Number: _______________________________
By signing this statement I verify that the representations herein are true. By making false statements on this document, I
realize I am committing a class D crime punishable under Maine law.
Signature of Certifying Individual: ___________________________________ Date: __________________
Signature of Applicant: ___________________________________________ Date: ___________________
All spaces on this form must be completed. If an item does not apply, write N/A for “not applicable.” Maine
Bureau of Motor Vehicles staff may contact you to verify the information provided about the Applicant.
State of Maine
Secretary of State – Bureau of Motor Vehicles
101 Hospital Street 29 State House Station
Augusta, Maine 04333
207-624-9000 ext. 52114; TTY Users call Maine relay 711
MVL 17 Rev 09/2015
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