Nonresident Driver Statement printable pdf download

DECAL NUMBER

Commonwealth of Massachusetts

SCHOOL USE ONLY

Registry of Motor Vehicles

Nonresident Driver Statement

PLEASE PRINT

School Year Beginning _________________

month

year

Pursuant to the provisions of M.G.L c.90 § 3, as amended by chapter 46 of the acts of 2003, this form must be completed in

quadruplicate by every nonresident enrolled as a full time student at a school or college in the Commonwealth who

operates a motor vehicle in Massachusetts that is registered in another state or country during any period beginning on

September 1

of any year, and ending on August 31

of the following year. This applies to students commuting from out-

of-state to a school in Massachusetts and students temporarily residing in Massachusetts. This completed form must be

filed with the Police department in the city or town where the school is located. The Police department must provide a

copy to the school, the local assessor, and the RMV. The school will issue the required decal, which must be affixed to the

uppermost center portion of the windshield. The penalty for a nonresident’s failure to comply as required is up to $200.00.

PART 1: NONRESIDENT STUDENT INFORMATION

LAST NAME

FIRST

MIDDLE iNITIAL

PERMANENT LEGAL RESIDENTIAL ADDRESS

CITY/TOWN

STATE/ZIP

COUNTRY

RESIDENTIAL ADDRESS WHILE ATTENDING SCHOOL

CITY/TOWN

ZIP

NOTE: REPORT ANY CHANGE OF PERMANENT OR TEMPORARY ADDRESS TO THE POLICE DEPARTMENT AND THE SCHOOL

NAME OF SCHOOL/COLLEGE & ADDRESS

CITY/TOWN

ZIP

PART 2: VEHICLE INFORMATION

REGISTRATION NUMBER

STATE, PROVINCE, AND COUNTRY OF REGISTRATION

REGISTRATION EXP. DATE

YEAR

MAKE

MODEL

COLOR

VEHICLE IDENTIFICATION NUMBER

VEHICLE OWNER’S LAST NAME

FIRST

MIDDLE INITIAL

VEHICLE OWNER’S ADDRESS

CITY/TOWN

STATE

PART 3: LIABILITY INSURANCE INFORMATION

This vehicle can only be operated during such time as the owner thereof maintains in full force a policy covering all of the

provisions in M.G.L., Ch. 90, Sec 3. Coverage sufficient to allow a “Yes” to both a) and b) is required.

Does this policy provide at least $20,000 coverage for injury or death to one person and $40,000 coverage for injury or

death to more than one person while the vehicle is being operated on the ways of Massachusetts? ___ YES ___ NO

Does this policy provide indemnity for any operator of this vehicle while being operated with the express or implied

consent of the owner? ____ YES ____ NO

NAME OF INSURANCE COMPANY & ADDRESS

EXPIRATION DATE OF POLICY

I HEREBY CERTIFY UNDER THE PENALTIES OF PERJURY THAT THE ABOVE INFORMATION IN EACH OF THE THREE

PARTS IS TRUE AND COMPLETE. I ALSO UNDERSTAND THAT A COPY OF THIS FILING WILL BE PROVIDED TO THE

LOCAL ASSESSOR WHERE I RESIDE.

DID YOU RECEIVE A WRITTEN WARNING FROM YOUR SCHOOL INDICATING A PENALTY OF UP TO $200.00 FOR YOUR

FAILURE TO FILE THE COMPLETED NONRESIDENT DRIVER STATEMENT WITH THE POLICE DEPARTMENT?

YES____ NO_____

SIGNATURE ___________________________________________

DATE _________________________________

Nonresident Driver Statement

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