Form Dr 2090 - Waiver Of Security Financial Responsibility January 2001

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DR 2090 (01/01)
COLORADO DEPARTMENT OF REVENUE
MOTOR VEHICLE BUSINESS GROUP
DRIVER CONTROL SECTION ROOM 164
DENVER CO 80261-0016
(303) 205-5613
WAIVER OF SECURITY
FINANCIAL RESPONSIBILITY
FRA Case Number
• If claimant is a corporation, waiver must be signed by an officer or authorized agent. Show title
of person signing.
• Waivers from insurance companies must show that the claim has been subrogated. This must be
signed by a representative of the insurance company or the claimant and insurance representative.
• A waiver must be signed by each person injured or by each person who received property damage.
Claimant's Name
Date of Accident
Debtor's Name
Address
An agreement has been made for the settlement and payment of damages claimed as a result of the motor
vehicle accident shown above.
As part of the agreement, claimant has waived the requirement that debtor be required to deposit or
maintain a deposit of security under the Financial Responsibility Law.
I understand that by signing this waiver, I have not given up any of my rights to collect the amount due
on this claim.
Claimant's Signature
Date
Title
SUBSCRIBED AND AFFIRMED, OR SWORN TO, BEFORE ME
Date
County
STATE OF ____________________________
Notary Signature
Commission Expiration Date

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