Form Mv-44dr-F - Nys Resident Disaster Victims Relief Supplemental Information And Attestation

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NYS RESIDENT DISASTER VICTIMS RELIEF
SUPPLEMENTAL INFORMATION AND ATTESTATION
P
C
I
B
LEASE
OMPLETE THE
NFORMATION
ELOW
Last Name
First Name
Middle Name
Date of Birth (Month/Day/Year)
/
/
Current New York State Address:
Street # and Name
Apt. #
City/Town
Zip Code
State
County
Telephone Number:
E-Mail Address
(
)
I am applying for a replacement: (check all that apply)
¨
Permit, Class __________
¨
Driver License, Class __________
¨
Non-Driver Identification Card
¨
Certificate of Registration
¨
License Plate(s)
¨
Certificate of Title
ATTESTATION
I certify that I am a New York State resident of one of the counties listed below. I am applying for a replacement driver
permit, driver license, non-driver identification card, certificate of registration, license plate(s), and/or certificate of title
that have been damaged or lost as a result of a disaster.
Effective Friday, November 9, 2012, these replacement documents will be issued at no charge.
Bronx
New York
Rockland
Kings
Queens
Suffolk
Nassau
Richmond
Westchester
ç
Date:
Sign Here
MV-44DR-F (11/15)

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