Form Hsmv 72871 - Florida Highway Safety And Motor Vehicles printable pdf download

Form Hsmv 72871 - Florida Highway Safety And Motor Vehicles

NOTIFICATION TO THE DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES

STUDENT COMPLIANCE WITH ENROLLMENT REQUIREMENTS

FOR A HOME EDUCATION PROGRAM

This is to provide verification to the Department of Highway Safety and Motor Vehicles that the

following student, who received Notice of Intent to Suspend/Withhold Eligibility for Licensure

due to non-attendance has been enrolled in a home based education program 30 consecutive

days.

Student’s Full Legal Name: ______________________________________________________

(First, Middle, Last)

Mailing Address: ______________________________________________________________

Driver License/Control Number: __________________________Gender: ____Male____Female

Date of Birth: _______/______/______ Social Security Number: _________________________

District Name: ___________________________ District Number: ________________________

School Name: ___________________________ School/Institution Number: ________________

Date: _______/_______/_______

Authorized Signature of School Official: ____________________________________________

(Signature must be notarized or school seal affixed)

Title: _________________________________________________________________________

Typed or Printed Name of Person Signing Form: ______________________________________

_________________________________________

Notary Public

State of Florida at Large

___________________________________ My commission expires: _______/_______/______

School Seal

Original signatures required.

_____________________________________________________________________________

For additional information contact:

Name________________________________________Telephone: _______________________

You may mail, fax or e-mail this completed form to: DHSMV, 2900 Apalachee Parkway, MS

#39, Tallahassee, Florida 32399-0570. The fax number is (850)-617-5095 and the e-mail

address is Truancy@flhsmv.gov. If the license is suspended, present this form to a driver

license or a tax collector’s office for reinstatement of your driving privilege. A $45

reinstatement fee is required for a suspended license.

Note: This form may only be accepted within 30 calendar days of its completion.

HSMV 72871 (07/15)

Form Hsmv 72871 - Florida Highway Safety And Motor Vehicles