Form Fs-48s - Financial Security Exemption Application - Storage

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FINANCIAL SECURITY EXEMPTION APPLICATION - STORAGE
FS-48S (7/15)
This document is an application for exemption from the Financial Security Law (as defined in section 318 of the NYS Vehicle and
Traffic Law). This application is to be completed by appropriate facility staff and signed by the facility manager or owner or
military official as well as by the registrant. Evidence that the vehicle is currently in compliance with the financial security sections
of the Vehicle and Traffic Law must accompany your application. Compliance may take the form of a current NYS insurance card,
plate surrender, a report of lost or stolen plates (MV-78B), or the expiration of your vehicle registration. Please be aware that
coverage will be confirmed with your insurance carrier. If this exemption involves multiple facilities or invoices, separate
applications must be completed. Send the original application and compliance documentation to NYS DMV, Insurance Services
Bureau, 6 Empire State Plaza, Albany NY 12228.
o
o
o
S
E
T
R
:
Commercial Secured
Military Base
Licensed Towing Facility
TORAGE
XEMPTION
YPE
EQUESTED
A. C
/R
/T
S
F
I
- Copy of invoice and advertisement must accompany application.
OMMERCIAL
EPAIR
OWING
TORAGE
ACILITY
NFORMATION
Facility Name
Address
Telephone Number
(
)
B. M
S
I
- Copy of registrant’s military ID must accompany application.
ILITARY
TORAGE
NFORMATION
Facility Name
Address
o
o
Telephone Number
Registrant on active duty while vehicle was stored
Yes
No
(
)
If “No”, please provide an explanation.
C. V
/R
I
EHICLE
EGISTRANT
NFORMATION
Registrant Name
Address
License Plate Number
Vehicle Year and Make
VIN
D. A
D
CTIVITY
ATES
Date vehicle entered facility: _____________________
o
o
Is the vehicle still in the facility’s possession?
YES
NO
If not, when was vehicle released to the motorist? __________________
Was this vehicle operated while in storage or involved in any motor vehicle accidents, Vehicle and Traffic Law violations or
o
o
parking violations during the period in question?
If “Yes”, please provide an explanation below:
YES
NO
A FALSE STATEMENT ON THIS APPLICATION MAY BE PUNISHABLE AS A CRIME UNDER THE NEW YORK STATE
PENAL LAW.
Print Registrant’s Name
_________________________________________________________________
ç
Date
_______________________
Registrant’s Signature
_________________________________________________________________
FALSE STATEMENTS ON THIS APPLICATION ARE PUNISHABLE BY LAW AND MAY RESULT IN THE SUSPENSION OR
REVOCATION OF YOUR BUSINESS CERTIFICATE(S). THE PERSON SIGNING THIS APPLICATION STATES THAT SHE OR
HE IS THE OWNER OR MANAGER OF THE FACILITY NAMED ON THIS APPLICATION OR A MILITARY OFFICIAL AND THAT
ALL INFORMATION PROVIDED IS TRUE.
Print Facility Owner’s/Manager’s/Military Official’s Name
______________________________________________________________
ç
Date
_______________________
Signature
____________________________________________________________________________
All Documentation is Subject to Review and Approval.
reset/clear

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