Financial Responsibility Acceptance Form
Applicant’s Date of Birth
Applicant’s Driver’s License/ID Number
Parent or Guardian Address (include city, state, and zip code) of Applicant
Financial Responsibility Acceptance:
The above-mentioned applicant applied for an Arkansas driver’s license. Before an
Arkansas driver’s license can be issued to any applicant under the age of 18, signature of
a parent or legal guardian assuming financial responsibility must be obtained in
accordance with Arkansas statute A.C.A. § 27-16-702.
If you have no objection to the issuance of a driver’s license to the above-mentioned
applicant and are willing to accept financial responsibility for the issuance of an Arkansas
driver’s license, please sign the following statement and have it notarized:
Before me, the undersigned authority, on this day personally appeared
, being by me duly sworn, states on oath that:
(Parent or Legal Guardian PRINTED Name)
1. Affiant is an individual of sound mind over the age of 18.
2. Affiant is the parent or legal guardian of the applicant.
Affiant accepts financial responsibility for issuance of a driver’s license to the applicant.
(Parent or Legal Guardian Signature)
SUBSCRIBED AND SWORN to before me this
***Please Note: This form is valid for thirty (30) calendar days from the date of the
notary’s signature. Failure to present this form to an examiner within the 30-day period
will result in the requirement to submit a new form.***
For questions contact: driverslicense@asp.arkansas.gov
06/14/2019
