Mva Form Icd 071 PDF Details

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.

QuestionAnswer
Form NameMva Form Icd 071
Form Length1 pages
Fillable?Yes
Fillable fields28
Avg. time to fill out5 min 51 sec
Other namesicd 071, mva maryland icd 071, form icd 071, cs 071 maryland mva form

Form Preview Example

Motor Vehicle Administration

6601 Ritchie Highway, N.E.

Glen Burnie, Maryland 21062

ICD-071 (12-13)

Maryland Vehicle Insurance Compliance Program – Certified 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

 

to

 

. During this time the vehicle was parked at

MM/DD/YY

 

MM/DD/YY

 

(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 12-109 b (2) of the Maryland Vehicle Law.

Signature Owner/Co-Owner

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 12-109(b) of the Maryland Vehicle Law.

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 12-109(b) of the Maryland Vehicle Law.

 

Witness Signature

Drivers License Number

 

Date

 

Daytime Phone Number

 

 

 

 

 

 

 

 

 

MVA Use Only

 

 

 

 

 

 

 

 

Moving Violation/Accident

No q

Yes q

Date:_______________

Case/Ticket #:________________

 

 

Prior Case:

No q

Yes q

Date:_______________

Case #:______________________

 

 

Adjustment Approved:

No q

Yes q

Amount:_____________

 

 

 

Authorized By:_ ________________________________________

ID:_ _________________

Date:__________________

 

For more information, please call: 410-768-7000 (to speak with a customer agent).

TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov

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certified statement empty spaces to fill out

Type in the requested details in the field Signature, Owner, Co, Owner Date, Daytime, Telephone, Number Section, Witness, Statement, of, Facts Signature, Witness Drivers, License, Number Date, Daytime, Phone, Number Witness, Signature MV, A, Use, Only Drivers, License, Number Date, Daytime, Phone, Number Moving, Violation, Accident and Prior, Case, Adjustment, Approved

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