Form Fl-17 - Report Of Unauthorized Use Of License/registration Page 3
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2
3D. Have you ever given permission to anyone to register a vehicle in your name?
Yes
No If “Yes”, explain:
E. Has a vehicle been registered in your name without your permission?
Yes
No
Please list all disputed vehicles and plate numbers:
F. Have you ever received a Certificate of Title for a vehicle you do not own?
Yes
No (If “Yes”, please attach the title.)
1. List your addresses for the past ten years, with the dates you lived at each address:
Address
Date From
Date To
–
–
–
–
–
–
2. List all vehicles you have owned in the last ten years. Provide the plate number, year and make of those vehicles:
Plate Number
Year/Make
Plate Number
Year/Make
SECTION 4: NOTARIZATION
Read the following statement, then sign below and have the statement notarized. We will not begin an investigation until this report is signed
and notarized.
FALSE STATEMENTS MADE IN THIS REPORT ARE PUNISHABLE AS A CRIME
IN ACCORDANCE WITH THE NEW YORK STATE PENAL LAW.
X
(Signature)
SWORN TO BEFORE ME
THIS
DAY OF
IN THE YEAR OF
.
NOTARY PUBLIC NUMBER
PAGE 2 OF 2
FI-17 (2/15)
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Parent category: Legal