Mva Form Icd 071 – Fill Out and Use This PDF

The MVA form ICD 071 is a document that you need to fill out if you're moving from one state to another with your vehicle.

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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.

Question	Answer
Form Name	Mva Form Icd 071
Form Length	1 pages
Fillable?	Yes
Fillable fields	28
Avg. time to fill out	5 min 51 sec
Other names	icd 071, mva maryland icd 071, form icd 071, cs 071 maryland mva form

12

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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