Dl-17 Statement of Non-ownership

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WARNING: Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500.00 and/or imprisonment up to one year (18 PA C.S. Section 4904(b)). DATE SIGNATURE IN INK I,___________________________________________________________, hereby state that I do not own any Motor Vehicles currently registered in the Commonwealth of Pennsylvania. I certify that all information given on this statement is true and correct. If using a Messenger Service, I hereby authorize the Department to furnish them with my driving record for the purpose of processing this form. PLEASE PRINT NAME ALL INFORMATION MUST BE COMPLETED If you are a registered voter in PA, would you like us to notify your county voter registration office of this change? ❑ YES ❑ NO If you are not a registered voter, you may contact your county voter registration office. DRIVER’S LICENSE NUMBER LAST NAME JR/ETC MIDDLE NAME FIRST NAME ZIP CODE STATE NEW STREET ADDRESS CITY CHANGE OR CORRECTION OF ADDRESS ADDRESS CHANGE - A Post Office Box number may be used in addition to the actual residence address, but cannot be used as the only address. STATEMENT OF NON-OWNERSHIP OF VEHICLE(S) PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION DL-17 (2-07) PA Department of Transportation • Bureau of Driver Licensing P.O. Box 68693 • Harrisburg, PA 17106-8693 DATE OF BIRTH (must be listed) TELEPHONE NUMBER (8:00 a.m. to 4:30 p.m.) ( ) E-MAIL ADDRESS (if applicable) Month Day Year

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Transcript of Dl-17 Statement of Non-ownership

Page 1: Dl-17 Statement of Non-ownership

WARNING: Misstatementoffactisamisdemeanorofthethirddegreepunishablebyafineofupto$2,500.00and/or imprisonmentuptooneyear(18PAC.S.Section4904(b)).

DATESIGNATUREININK

I,___________________________________________________________,herebystatethatI

do not own any Motor Vehicles currently registered in the Commonwealth of Pennsylvania.Icertifythatallinformationgivenonthisstatementistrueandcorrect.IfusingaMessengerService, I hereby authorize the Department to furnish them with my driving record for thepurposeofprocessingthisform.

PLEASEPRINTNAME

ALL InformAtIon must Be CompLeted

If you are a registered voter in pA, would you like us to notify your county voter registration office of this change? ❑ Yes ❑ noIf you are not a registered voter, you may contact your county voter registration office.

DRIVER’SLICENSENUMbER LASTNAME jR/ETC

MIDDLENAMEFIRSTNAME

ZIp CodestAte

neW

street

Address

CItY

CHAnGe or CorreCtIon of Address

Address CHAnGe - A post office Box number may be used in addition to the actual residence address, but cannot be used as the only address.

stAtement of non-oWnersHIp of VeHICLe(s) pLeAse tYpe or prInt In BLue or BLACk Ink ALL InformAtIon

DL-17(2-07)

PADepartmentofTransportation•bureauofDriverLicensingP.O.box68693•Harrisburg,PA17106-8693

DATEOFbIRTH(mustbelisted) TELEPHONENUMbER(8:00a.m.to4:30p.m.)

(        )E-MAILADDRESS(ifapplicable)

MonthDayYear

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