Sf 0259 Form – Fill Out and Use This PDF

TENNESSEE DEPARTMENT OF SAFETY

AND HOMELAND SECURITY

MINOR/TEENAGE AFFIDAVIT AND CANCELLATION

Minor/Teenage Affidavit

I, the undersigned, make oath in due form of law that I am the _____________________________________

(Relationship)

of ____________________________________________________________________________________,

(Full Name of Applicant)

Social Security Number: __________________________ Date of Birth: ________________________ and

(Month/Day/Year)

I hereby join in application of said applicant for a Tennessee Driver License / Photo Identification License.

(Circle One)

For Parent/Legal Guardian of Teenage Applicants for Driver License Only:

I hereby accept all of the responsibilities and obligations imposed under the provisions of Tennessee Annotated Code Annotated 55-50-311 and 312 as the parent/legal guardian of said applicant, who is under eighteen (18) years of age, and I fully understand and agree that any negligence or willful misconduct of the said applicant while operating a motor vehicle prior to his/her eighteenth (18th) birthday shall be imputed to me and I shall be jointly and severally liable for any damages caused by him/her while operating a motor vehicle.

Cancellation of Teenage Affidavit

I, the undersigned, state I signed the application of ________________________________________________

(Full Name of Applicant)

Social Security: __________________________ Driver License Number: ____________________________

Date of Birth: __________________________________ and now desire to be relinquished of all responsibilities

(Month/Day/Year)

and obligations imputed to me and I shall not be liable for any damages caused by him/her should they operate a motor vehicle. Therefore, I hereby request his/her license be cancelled.

Affiant’s Official Signature:

___________________________________________________________________________________________

Parent/Legal Guardian	Driver License Number	Driver License State	Social Security No.
Legal Residence:

___________________________________________________________________________________________

House, Street, and Apartment Number

CITY

STATE

ZIP CODE

Sworn to, or affirmed, before me and subscribed in my presence this the _________ day of

_________________________

20________.

NOTARY PUBLIC

OR EXAMINER _________________________________________

My Commission expires the ____________ day of _______________________ 20_______.

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Summary of Tennessee Financial Responsibility Law

Tennessee Code Annotated, Title 55

The law requires that you be advised of your obligations and how this law may affect your driving and vehicle registration privileges. The purpose of the law is to protect you and the public from financially irresponsible drivers who become involved in an accident, as well as from drivers who have repeated violations and disregard of the law.

Liability insurance provides coverage for damages you cause to other persons. Uninsured motorist insurance provides coverage for the damages uninsured persons cause you. State law requires your agent to offer you coverage against uninsured drivers.

1.IF YOU CONTRIBUTE TO A REPORTABLE ACCIDENT you may be required to establish financial responsibility for that accident. If so, you will be required to file an accident report with the Department of Safety and Homeland Security. You will have to do one of these three (3) things when you file your report: (1) show proof you had liability insurance at the time of the accident; (2) obtain notarized releases from all parties that file claims with the department; (3) post cash or corporate security bond with the department for the amount of damages sustained by the other parties. IF YOU DO NOT COMPLY WITH ONE OF THESE REQUIREMENTS YOU WILL HAVE YOUR DRIVING AND REGISTRATION PRIVILEGES REVOKED.

2.THE FINANCIAL RESPONSIBILITY LAW requires officers to ask drivers for proof of financial responsibility when they are charged with moving violations or involved in traffic accidents. Proof of financial responsibility is: evidence of liability insurance in effect at the time of the violation or accident; proof the driver has qualified as a self-insurer with the Department of Safety and Homeland Security; or proof the driver has posted a bond with the Department of Safety and Homeland Security. If convicted of failure to have such proof in the vehicle, the driver may be fined $100.00 and the driver license will be suspended.

3.IF YOU DO NOT TURN IN A DRIVER LICENSE, VEHICLE LICENSE PLATE, OR VEHICLE REGISTRATION WITHIN 20 DAYS when any is revoked, suspended or canceled, you will owe the department a $75.00 fee in addition to other required reinstatement fees.

4.IF YOUR DRIVING PRIVILEGES ARE REVOKED DUE TO A CONVICTION OR FAILURE TO FILE SECURITY AFTER AN ACCIDENT, in addition to all other requirements, you must have a liability insurance carrier file an SR-22 form with this department before your privileges can be reinstated.

Questions regarding Tennessee’s Financial Responsibility Law should be directed to: Tennessee Department of Safety and Homeland Security, P.O. Box 945, Nashville TN 37202; telephone number Toll- Free 1-866-903-7357

AFFIDAVIT OF APPLICANT:

“I CERTIFY THAT I UNDERSTAND TENNESSEE’S FINANCIAL RESPONSIBILITY LAW AS SET FORTH IN TENNESSEE CODE ANNOTATED, TITLE 55 AND I AGREE TO ABIDE BY IT”

Signature of Applicant ____________________________________________	Date:__________________
Parent’s Signature ________________________________________________	Date:__________________
Parent’s Signature (if Applicant is under Age 18)
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