Affidavit / Consent For Minor To Drive - Illinois Secretary Of State Forms printable pdf download

Affidavit / Consent For Minor To Drive - Illinois Secretary Of State Forms

FIELD SERVICES

Office of the Secretar y of State

2701 S. DIRKSEN PKWY.

SPRINGFIELD, IL 62723

Driver Ser vices Depar tment

217-782-7044

AFFIDAVIT / CONSENT FOR MINOR TO DRIVE

I, ________________________________________________, Driver’s License/ID Number __________________________________,

Name

Telephone Number ____________________________________________________________________________________________,

State and affirm that I am legally responsible for the below mentioned minor:

___________________________________________, ________________, Driver’s License/IP Number _______________________,

Name

Date of Birth

and that my relationship to the above-mentioned minor is:

___________________________________________________________________________________________________________.

Parent/Legal Guardian, Other Responsible Adult

If other responsible adult, explain relationship: _____________________________________________________________________

I hereby certify and give my written consent to the Secretary of State for the issuance of a driver’s license to the minor named on

this affidavit. I certify that the above-mentioned minor has had 50 hours of behind-the-wheel practice time, including 10 hours of

night-time driving and that the minor is sufficiently prepared and able to safely operate a motor vehicle.

Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109), the undersigned cer-

tified that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information

and belief, and as to such matters the undersigned certified as aforesaid that he/she verily believes the same to be true.

Signature: ___________________________________________________________________________________________________

Address: _____________________________________________________________________________________________________

City: ____________________________________________________State _________________ ZIP Code______________________

Subscribed and sworn to before me this ____________________________ day of _________________________________, 20_____.

___________________________________________________

Notary Public

PLACE NOTARY

SEAL HERE

My commission expires ________________________________

Printed on recycled paper.

Printed by authority of the State of Illinois. August 2008 — 50M — DSD X 174.1

Affidavit / Consent For Minor To Drive - Illinois Secretary Of State Forms