Mva form Icd 071 is a Maryland form which can be used to request medical records from a health care provider. The form can be used to request records for an individual or for a group of individuals, and it can be used to request records that are either current or historical. In order to complete the form, you will need to provide information about yourself and the individuals whose records you are requesting, as well as the specific types of records that you would like to receive. You will also need to provide contact information so that the health care provider can get in touch with you if they have any questions.
You could find it helpful to understand the amount of time you will need to fill in this mva form icd 071 and just how long the form is.
| Question | Answer |
|---|---|
| Form Name | Mva Form Icd 071 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | maryland certified statement, mva maryland icd 071, certified statement, icd 071 |
MOTOR VEHICLE ADMINISTRATION
6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062
Maryland Vehicle Insurance Compliance Program – Certiied Statement
SECTION 1: OWNER’S INFORMATION AND STATEMENT OF FACTS
CASE NUMBER
INSURANCE CANCELLATION DATE
INSURANCE COMPANY
TAG NUMBER
TITLE NUMBER
VEHICLE IDENTIFICATION NUMBER:
YEAR:
MAKE:
VEHICLE OWNER (First, Last Name):
OWNER’S DRIVERS LICENSE NUMBER:
The vehicle listed above has not been driven, involved in an accident, or issued a citation during period of insurance lapse
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to |
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. During this time the vehicle was parked at |
MM/DD/YY |
MM/DD/YY |
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(Location)
(Street Address) |
(CIty) |
(State) |
(Zip Code) |
For the following reason(s):
(Supporting documentation attached)
I certify, under penalty of perjury, that the statements made above are true and correct to the best of my knowledge, information and belief, under Section
Signature |
Date |
Daytime Telephone Number |
SECTION 2: WITNESS STATEMENT OF FACTS
Witness A or Repair Facility - Business License #
I certify, under penalty of perjury, that the statements made above by the vehicle owner are true and correct to the best of my knowledge, information and belief, under Section
Signature Witness |
Drivers License Number |
Date |
Daytime Phone Number |
Witness B
I certify, under penalty of perjury, that the statements made above by the vehicle owner are true and correct to the best of my knowledge, information and belief, under Section
Witness Signature |
Drivers License Number |
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Date |
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Daytime Phone Number |
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MVA Use Only |
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Moving Violation/Accident |
No q |
Yes q |
Date:_______________ |
Case/Ticket #: _______________ |
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Prior Case: |
No q |
Yes q |
Date:_______________ |
Case #: _____________________ |
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Adjustment Approved: |
No q |
Yes q |
Amount: ____________ |
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Authorized By: ________________________________________ |
ID: _________________ |
Date:__________________ |
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For more information, please call:
TTY for the hearing impaired: