Form Dmv 005 – Fill Out and Use This PDF

Reno/Sparks/Carson City (775) 684-4DMV (4368)

Las Vegas Area (702) 486-4DMV (4368)

Rural Nevada (877) 368-7828

Fax: (775) 684-4992

Website: www.dmvnv.com

Certification of Nevada Residency

This certification is used to support a claim that you are a Nevada resident. You must be a resident of Nevada to be eligible for a Driver’s License (DL), Driver Authorization Card (DAC) or Identification Card (ID) [NRS 483.250 (7), 483.290 (5)(b), and 483.934]. The definition of “resident” is found in NRS 483.141.

This certification will be accepted as one form of evidence for your principal residence address.

Customer Information

Name

Residence Address	City	State		Zip
Mailing Address if different	City	State		Zip
DL/DAC/ID Number	Social Security Number (not required for a DAC)

An original or certified copy of any of the following documents must be submitted with this form. Each document must be dated within the previous 60 days or be the most current available.

•A pr oper t y t ax r ecor d, ut ilit y bill, m or t gage docum ent or deed, r ent r eceipt , or a lease or r ent al agr eem ent

•Enr ollm ent r ecor ds or st udent ident ificat ion car d fr om an educat ional inst it ut ion locat ed in Nev ada r eflect ing y our Nev ada r esidence addr ess

•Mot el, hot el, cam pgr ound or r ecr eat ional v ehicle par k r eceipt s show ing t hat y ou hav e been r esiding in Nev ada for at least 3 0 consecut iv e day s

•Or iginal, cur r ent cer t ificat e of v ehicle liabilit y insur ance issued by a Nev ada- based car r ier w hich r eflect s y our Nev ada r esidence addr ess ( CANNOT BE HANDW R IT T EN )

•Cr edit car d st at em ent , m edical bill, cellular t elephone bill, or ot her st at em ent or r equest for pay m ent m ailed t o y our Nev ada r esidence addr ess

•A st at em ent fr om a r elief agency or shelt er ( For m DMV1 1 5 ) t hat y ou hav e no act ual r esidence, but cur r ent ly r eceiv e assist ance in Nev ada

•Vot er r egist r at ion car d issued by t he Nev ada Secr et ar y of St at e for t he m ost r ecent elect ion per iod w hich r eflect s y our Nev ada r esidence addr ess

•Docum ent s show ing y ou hav e a cur r ent account at a bank or cr edit union in Nev ada

•Milit ar y Leav e and Ear nings St at em ent ( LES) t o ev idence Nev ada r esidency w hen deploy ed out side of Nev ada

•A docum ent show ing r eceipt of public assist ance fr om St at e of Nev ada agency

This certification must be signed by a second party attesting to Nevada residency if the applicant is not able to produce one of the above required documents with this certification. The second party must reside at the same residential address, accompany the applicant, and present proof of residency in the form of one document listed above.

DISCLOSURE STATEMENT: The Privacy Act as passed by the United States Congress authorizes the use of your Social Security number for the purpose of verifying your identity. This number must be provided and will be used in the administration of driver license laws as required by NRS 483.290. (This is not required for a DAC.)

I hereby certify under penalty of perjury that all statements in this application are true and correct. I agree and understand that any misstatement of material facts may cause cancellation and/or denial of my driver’s license or identification card under NRS 483.420 and NRS 483.530, respectively. I further understand that anymisstatement of facts maybe a misdemeanor or felonyunder NRS 483.530 and may be punishable pursuant to NRS 193.130.

Applicant’s Signature		Date
Signature of Additional Resident Attesting to Nevada Residency		Driver’s License or Identification Card No.

DMV-005 (Rev. 10/2013)