Free 39531.FH8 - Indiana

AGREEMENT OF FINANCIAL LIABILITY - IC 9-24-9-3, 4, 5 (To be used if applicant is under 18 years of age) Notice: If the applicant is under the age of 18, the following statement must be signed and sworn to or affirmed (before a person authorized to administer oaths) by the father or mother or guardian having custody. In the event neither parent is living within the state and the applicant has no guardian, this statement may be signed by the person having custody of the applicant or by an employer of said applicant and in the event there is no parent, guardian, or employer, then by any other responsible person willing to assume the obligations imposed by this statement.

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_____________________________________________ (herein minor) has applied for a driver license or a learner permit. The undersigned AFFIANT hereby agrees to be responsible, jointly and severally with the MINOR for any injury of damages which said MINOR may cause, by reason of operation of a motor vehicle, in such cases as the MINOR is found to be liable for such injuries or damages. The assumption of liability by the AFFIANT shall terminate upon the MINOR'S eighteenth birthday or emancipation . I swear or affirm that the information I have entered on this form is correct. I understand that making a false statement on this form may constitute the crime of perjury.

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Name of affiant Address of affiant Relationship to applicant Parent with custody Guardian with custody Person with custody Employer Other (specify) ____________________

STATE OF INDIANA COUNTY OF_______________________

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Date Commission expires County of residence

Subscribed and sworn to before me this ____ day of __________________, _________.
Signature of Notary Public Printed or typed name of Notary Public State Form 39531 (R3 / 1-02)