NewYorkStateDepartmentofMotorVehicles
STATEMENT OF IDENTITYAND/OR RESIDENCE
ForApplicants Represented by Government or Government-Approved Facilities
This document is used for Identityand/orResidenceOnlyand cannotbe used for ProofofDateofBirth.
Proof of Date of Birth and a Social Security card are required.
This statement may only be used by an applicant who is mentally or physically challenged, is represented by a Government or Government- Approvedfacility,ANDwhocannotprovidesufficientproofof:
➤IdentityfromtheproofslistedonformID-44(ProofsofIdentity);and/or
➤ResidencefromtheproofslistedonformID-44EDL(ProofsofIdentity,CitizenshipandResidence).Pleasenote:oneadditionalproof ofresidencemustaccompanythisstatement.Proofofresidenceisonlyrequiredwhenapplyingforanenhanceddocument.
TheapplicantandhisorherapprovedfacilityrepresentativemayusethefollowingmethodforPROOFOFNAMEAND/ORRESIDENCE:
➤Theapprovedrepresentativemust accompany the applicantwhenheorsheappliesforapermit/IDcardand must sign this form in the presence of a Motor Vehicle Representative.
➤Theapplicant’srepresentativemustbeagovernmentorgovernment-approvedfacilityrepresentative,andmustprovidehis/her originalfacilityIDcard/documentalongwithaletteronthefacility’sletterhead,signedbytherepresentative’ssupervisor.Thisletter mustverifytheapplicant’sname,dateofbirth,address,height,eyecolor,thenameofthefacilityandthenameoftherepresentative. Iftheletterissubmittedfromagovernment-approvedfacility,thelettermustindicatethenameoftheNYSfacilityandthefacility’s certificatenumber.
➤TherepresentativemusthaveavalidNewYorkStatePhotoDriverLicense/Permit/orNon-DriverIdentificationCard,andmust showthisproofalongwiththeabovedocumentsatthetimeofapplication.
CERTIFICATION
I, ___________________________________________________________________________________, certify as the Representative
(Name of Representative)
of______________________________________________________________________________________________,whoresidesat
(Name ofApplicant)
_____________________________________________________________________________________________________________
(Applicant’sAddress)
that this name is the name by which (s)he is commonly known and that (s)he resides at the address above. To the best of my knowledge, (s)he has not obtained or applied for a learner permit, non-driver identification card or driver license in any other name. I understand that any false statement I have made on this certification is a misdemeanor under Section 392 of the Vehicle & Traffic Law. This certification mustbeaccompaniedbyanoriginalletterfromthegovernmentfacilitythathasapprovedtheapplicant’srepresentative(seeabove).
IMPORTANT: DO NOT SIGN THIS FORM UNTILYOUARE WITHAMOTOR VEHICLE REPRESENTATIVE.
APPLICANT’S REPRESENTATIVE SignHere ç_______________________________________________________
PrintYourName:________________________________________________________________________________________________
IdentificationNo.fromyourDriverLicense,PermitorNon-DriverIDCard:_________________________________________________
PrintYourFacility’sName:Facility’sPhoneNo.:
Facility’sMailingAddress:
IMPORTANT: DO NOT SIGN THIS FORM UNTILYOUARE WITHAMOTOR VEHICLE REPRESENTATIVE.
APPLICANT SignHereç _________________________________________________________
OFFICE USE ONLY
ProofsofIdentifyPresentedbyRepresentative(allarerequired): NYSPhotoDriverLicense/Permit/Non-DriverID
Government or Government-Approved Facility Letter GovernmentorGovernment-ApprovedFacilityIDCard/document Signature of PersonAccepting Proof ç ____________________________________________________________________
Title of PersonAccepting Proof: ________________________________________________
Office: _______________________________________________________________ Date __________________________
MV-45A(4/11) |
www.dmv.ny.gov |
