AFFIDAVIT OF REVOCATION FINANCIAL RESPONSIBILITY
State Form 45425 (R2 / 8-96)
I, ________________________________________________ , do hereby revoke my assumption of financial responsibility for _________________________________________________________ , Indiana driver's license number _______________ - ______________ - ______________ , under Indiana Code 9-24-9 et al. I acknowledge that this revocation will also act as an invalidation of the driving privileges of the above named minor.
I swear or affirm that the above is true and correct, and that any false statement may constitute the crime of perjury.
Date (month, day, year)
Signature of parent or guardian
AFFIDAVIT OF REVOCATION FINANCIAL RESPONSIBILITY
State Form 45425 (R2 / 8-96)
I, ________________________________________________ , do hereby revoke my assumption of financial responsibility for _________________________________________________________ , Indiana driver's license number _______________ - ______________ - ______________ , under Indiana Code 9-24-9 et al. I acknowledge that this revocation will also act as an invalidation of the driving privileges of the above named minor.
I swear or affirm that the above is true and correct, and that any false statement may constitute the crime of perjury.
Date (month, day, year)
Signature of parent or guardian