Fillable DECLARATION OF HOMELESS STATUS (Department of Motor Vehicles )

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DECLARATION OF HOMELESS STATUS (Department of Motor Vehicles )

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DMV-128 (Revised 12/2019)
Reno/Sparks/Carson City (775) 684-4DMV
(4368)
Las Vegas Area (702) 486-4DMV
(4368)
Fax: (775)
684-4992
Website:
dmvnv.com
DECLARATION OF HOMELESS STATUS
This form must be submitted along with a DMV-002 (Application for Driving Privileges or ID Card).
I hereby certify under penalty of perjury that all statements in this application are true and correct. I
agree and understand that any misstatement of material facts may cause cancellation and/or denial of
my driver’s license, instruction permit or identification card under NRS 483.420 and 483.530. I further
understand that any misstatement of facts may be a misdemeanor or felony under NRS 483.530 and
may be punishable pursuant to NRS 193.130.
SIGNATURE OF APPLICANT
DATE
Signatures must be originals. Photocopies are not acceptable.
Changes may not be made to this form once it is signed.
LAST NAME (Please Print)
FIRST NAME
MIDDLE NAME
SUFFIX
ADDRESS WHERE I AM STAYING
STATE
ZIP
25 AND OLDER
NRS 483.417 and NRS 483.825
I am requesting a duplicate:
Non-Commercial Driver’s License
Instruction Permit
Identification Card
Fees will be waived one time only and you must
reimburse the Department the cost of the photo fee
when you renew your card, if employed at that time.
UNDER 25
483.410 and 483.820
I am requesting an/a:
Original Duplicate Renewal
(Choose one)
Non-Commercial Driver’s License
Driver Authorization Card
Instruction Permit
Identification Card
All fees for this issuance will be waived one time
only and are not required to be reimbursed at any
time.
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DECLARATION OF HOMELESS STATUS (Department of Motor Vehicles )

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Completed 24 December 2020

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