Affidavit For Hardship License
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1
2AOC- 492.A
Doc. Code: AFHD
Case No. ____________________
Rev. 5-16
Page 1 of 2
l e x
Court
____________________
e t
j u s t i t i a
Commonwealth of Kentucky
County
____________________
Court of Justice
Division
____________________
KRS 189A.400-.460
Affidavit For Hardship License
COMMONWEALTH OF KENTUCKY
PLAINTIFF
VS.
_______________________________________________
DEFENDANT
The undersigned Affiant is the [ ] employer/self employed, [ ] educator, [ ] physician, or [ ] ADE
program director for the above-named Defendant. Pursuant to KRS 189A.410 (see page 2), the undersigned states
under oath that the above-named Defendant should be granted a hardship driver’s license for the reason(s) stated
below, including the specific days and times when the Defendant is required to drive.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
If Employer/self-employed please provide the following information: Affiant’s Business/Employer’s name and address,
Affiant’s title, Affiant’s phone number on page 2.
Driving is necessary on the following days and at these specified times:
From:
To:
Mon.
______________________ m.
____________________ m.
Tues.
______________________ m.
____________________ m.
Wed.
______________________ m.
____________________ m.
Thurs. ______________________ m.
____________________ m.
Fri.
______________________ m.
____________________ m.
Sat.
______________________ m.
____________________ m.
Sun.
______________________ m.
____________________ m.
WHEREFORE, Affiant prays that the above-named Defendant’s Application for Hardship Driver’s License
NOTICE: Pursuant to KRS 189A.440(3), knowingly assisting Defendant in making a false application
be granted.
statement is a Class A Misdemeanor and results in revocation of the person’s operator’s license for six (6) months.
___________________________________________
___________________________________________
Affiant’s Name
Affiant’s Signature
(Please Print)
Subscribed and sworn to before me by the Affiant, this ______ day of ______________________, 2_______.
My commission expires: __________________, 2_______.
______________________________________
Notary Public
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