Power Of Attorney For Liability Insurance Hearing

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Form FS-45
Power of Attorney for Liability Insurance Hearing
KNOW ALL MEN BY THESE PRESENTS, the undersigned:
__________________________________________________________________________________________
Legal Owner(s) Of the following described motor vehicle:
Make: _________________________________________ Type: _________________________________
License Plate
Number: ________________________Vehicle Identification Number (VIN):_______________________
Year Built:__________________________ Model: ____________________________________________
Does (do) hereby authorize and irrevocably appoint:
_____________________________________________________________________________________
Agent acting under power of attorney
as my (our) true and lawful agent to act and represent in the name, place and stead of the undersigned, any
certificate of title or insurance covering the vehicle described above in whatever manner necessary as he/she
may deem fit and proper to effect the conduct of a hearing regarding liability insurance coverage of said
vehicle and may provide evidence, statement and witness and does (do) hereby ratify and confirm whatever
action said agent shall or may take by virtue hereof in the premises.
IN WITNESS HEREOF, the undersigned has executed this instrument this
______________________________________ day of___________________________ , __________
_____________________________________________________________________________________
Full Signature of owner(s)
_____________________________________________________________________________________
Full Signature of owner(s)
Date: ________________________________ County: ____________________ State: ___________
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that
he or she voluntarily signed the foregoing document for the purpose stated therein and in the capacity indicated:
_____________________________________________________________________________________
Name(s) of Principal(s)
Printed or typed name: __________________________________________________________________
Notary Signature: ______________________________________________________________________
My commission expires ______________________
FS-45
(5/08)
(SEAL)

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