Form Mv-18g - Service Member'S Affidavit For Mandatory Insurance Relief

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MV-18G (Revised 04-04)
Service Member’s Affidavit for Mandatory Insurance Relief
Instructions: Except for the signatures, this form must be typed or printed electronically or legibly by-
hand in blue or black ink. From this department’s website ( ), this form may be
completed on-line for printing, signing and submission.
Service Member’s Full Legal Name
Driver’s License Number & State of Issue
hereby state that during my absence from the State of Georgia pursuant to military orders, my
motor vehicle,
Vehicle Identification Number (VIN)
Year Model & Make of Vehicle
did not have the minimum required liability insurance coverage as defined by law (Ref. §40-2-
137(a)(2) of the OCGA), and my motor vehicle was not driven on the public roads of the State
of Georgia. My vehicle was stored or parked at:
Location Where Vehicle Was Stored or Parked
during the following period of time:
TO (Date Out of Storage/Parked)
FROM (Date In Storage/Parked
I further state that I have obtained the required liability insurance coverage for my vehicle in
accordance with the Georgia Motor Vehicle Safety Responsibility Act.
I do solemnly swear or affirm under criminal penalty for the commission of a felony that the
statements contained herein are true and accurate.
Service Member’s Signature
Notary Public’s Acknowledgement
Sworn to and subscribed before me this _______ of _______________________, ___________
Notary’s Printed Name:
Date My Notary Commission Expires:
Notary’s Signature & Seal or Stamp:
Certification of Service Member’s Commanding Officer
I, hereby certify that the above named service member was deployed and residing out of the
State of Georgia during the period of time stated in this affidavit.
Printed Name
Military Reservation (Base)
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