Fillable Affidavit For Hardship License (Page 2 of 2) in pdf

Affidavit For Hardship License Page 2

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AOC-492.A

Rev. 5-16

Page 2 of 2

If Employer/self-employed please provide the following information:

Affiant’s Business/Employer’s Name

_______________________________________________________________

Affiant’s Business/Employer’s Address _______________________________________________________________

_______________________________________________________________

Affiant’s Title ____________________________________________________________________________________

Affiant’s Phone ___________________________________

INFORMATION REQUIRED PURSUANT TO KRS 189A.410

FOR ISSUANCE OF HARDSHIP LICENSE

1. If the license is sought for employment purposes: A written, sworn statement from your employer

detailing your job, hours of employment, and the necessity for you to use a motor vehicle either in work

at the direction of your employer during work hours, or in travel to and from work. If you are self-employed,

provide the described information together with a sworn and notarized statement attesting to the truth

of the above information.

2. If the license is sought for education purposes: A written, sworn statement from the school or

educational institution that you attend containing your class schedule, courses being taken, and

necessity for you to use a motor vehicle in travel to and from school or other educational institution.

A license for educational purposes shall not include participation in sports, social, extracurricular,

fraternal or other noneducational activities.

3. If the license is sought for medical purposes: A written, sworn statement from a physician or other

medical professional licensed (but not certified) under Kentucky laws, attesting to your normal hours of

treatment, and the necessity to use a motor vehicle to travel to and from the treatment.

4. If the license is sought for alcohol or substance abuse education or treatment purposes: A written,

sworn statement from the director of any alcohol or substance abuse education or treatment program

as to the hours in which you are expected to participate in the program, the nature of the program, and

the necessity for you to use a motor vehicle to travel to and from the program.

5. If the license is sought for court-ordered counseling or other programs: A copy of any court order

relating to treatment, participation in driver improvement programs, or other terms and conditions

ordered by the court relating to you which require you to use a motor vehicle in traveling to and from the

court-ordered program. The court order must include the necessity for use of a motor vehicle.

6. A sworn statement must be signed by a notary public.

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Affidavit For Hardship License Page 2

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