AGREEMENT OF FINANCIAL LIABILITY - IC 9-24-(3)(4)(5)
(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's license or a learner's 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
M I NOR i s f ou nd t o b e li a bl e fo r su ch i nj u ri es o r d am a ges .
The assumption of liability by the AFFIANT shall terminate upon the
MINOR'S eighteenth birthday or emancipation .
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) ____________________
STATE OF INDIANA
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 (R2/2-94)