ICD-071 PDF Details

Section 1 is the Owner's Information and Statement of Facts; Section 2 is the Witness Statement of Facts.

Parking: the form states where the vehicle was parked during this time and the reasons; supporting documents should be attached to this form.

Who signs: Signature of Owner and Signature of Co-Owner; Witness Signature of Witness A or Repair Facility and of Witness B.

Witnesses: each certifies under penalty of perjury that the vehicle owner's statements are true and correct to the best of their knowledge, information and belief.

For more information: call 410-768-7000 (to speak with a customer agent); TTY for the hearing impaired: 1-800-492-4575.

Question	Answer
Form Name	ICD-071
Form Length	1 page
Fillable?	Yes
Fillable fields	40
Avg. time to fill out	7 min
Edition	06-23
For more information	Call 410-768-7000 (to speak with a customer agent)
Other names	ICD-071, ICD071, ICD 071, Form ICD-071, MVA ICD-071, Maryland Vehicle Insurance Compliance Program Certified Statement
Official source	ICD-071 (Rev 06-23), Maryland Motor Vehicle Administration

How to Fill Out Form ICD-071

Form ICD-071 at a glance

What it is: ICD-071 is the Maryland Vehicle Insurance Compliance Program - Certified Statement.

Who signs: For Signature of Owner, enter the Signature, Date and Daytime Telephone Number. If there is a co-owner, enter the Signature, Date and Daytime Telephone Number for Signature of Co-Owner. For Witness A or Repair Facility, enter the Witness Signature, Driver's/Business License Number, Date and Daytime Telephone Number. For Witness B, enter the Witness Signature, Driver's License Number, Date and Daytime Telephone Number.

A filled-in Form ICD-071 example: an owner explains an insurance lapse

Form ICD-071 example filled out, example: an owner explains an insurance lapse — Dana Sample, a vehicle owner, completes Section 1 of Form ICD-071. The insurance was cancelled on 03/01/26 and the vehicle sat parked in the garage until 03/31/26. The picture shows Section 1 filled in, and none of its entries is real. The lapse starts on the cancellation date. The owner signs alone, so Signature of Co-Owner stays empty. Section 2: Witness Statement of Facts is left blank because the witnesses sign after the owner.

How to fill out Form ICD-071, box by box

Section 1: Owner's Information and Statement of Facts

Under Section 1: Owner's Information and Statement of Facts, enter the Case Number, Insurance Cancellation Date, Insurance Company, Tag Number, Title Number, Vehicle Identification Number, Year and Make.

Period of insurance lapse, where the vehicle was parked and the reasons

The vehicle listed has not been driven, involved in an accident or issued a citation during period of insurance lapse from (MM/DD/YY) to (MM/DD/YY).

During this time, the vehicle was parked at the Street Address, City, State and Zip Code you enter.

Write the reasons on the line after For the following reasons.

Supporting documents should be attached to this form.

Signature of Owner

Certify under penalty of perjury that the statements made above are true and correct to the best of knowledge, information and belief, under Section 12-109b (2) of the Maryland Vehicle Law.

For Signature of Owner, enter the Signature, Date and Daytime Telephone Number.

Signature of Co-Owner

If there is a co-owner, enter the Signature, Date and Daytime Telephone Number for Signature of Co-Owner.

Section 2: Witness Statement of Facts

Under Section 2: Witness Statement of Facts, Witness A or Repair Facility and Witness B each certify, under penalty of perjury, that the statements made above by the vehicle owner are true and correct to the best of knowledge, information and belief, under Section 12-109(b) of the Maryland Vehicle Law.

For Witness A or Repair Facility, enter the Witness Signature, Driver's/Business License Number, Date and Daytime Telephone Number.

For Witness B, enter the Witness Signature, Driver's License Number, Date and Daytime Telephone Number.

Common questions about Form ICD-071

How to contact MVA Maryland?

For more information, please call 410-768-7000 (to speak with a customer agent). TTY for the hearing impaired: 1-800-492-4575. Visit www.MVA.Maryland.gov.

Sources

[1] Form ICD-071 (06-23), Maryland Vehicle Insurance Compliance Program - Certified Statement, Maryland Motor Vehicle Administration (the Official source link on this page).

ICD-071: Maryland MVA Vehicle Insurance Compliance Program Certified Statement