Fillable DECLARATION OF RESPONSIBILITY (Department of Motor Vehicles )

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DECLARATION OF RESPONSIBILITY (Department of Motor Vehicles )

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555 Wright Way
Carson City, NV 89711
Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas area (702) 486-4DMV (4368)
dmvnv.com
NVL019 (8/2015) Signatures must be originals. Photocopies are not acceptable.
Changes may not be made to this form once it is signed and witnessed
DECLARATION OF RESPONSIBILITY
NRS Chapters 485 and 482
I,
,
declare that, while this vehicle is registered in my name, I will
Printed Full Legal Name of registered owner accepting full responsibility
continuously provide in my name, security as required by NRS 485.185, either by a motor vehicle liability insurance policy or by
qualifying as a self-insurer in compliance with law. There is no grace period. NOTE: THE VEHICLE MUST BE INSURED BY
AN INSURANCE COMPANY LICENSED IN THE STATE OF NEVADA. The statement, “the coverage meets the requirements
set forth in NRS.485.185” must be included on the Nevada Evidence of Insurance card. Out-of-State insurance will not be
accepted. Trailers are exempt from insurance requirements.
In accordance with NRS Chapters 482 and 485, if the motor vehicle liability insurance on my registered vehicle lapses for one
day or more, I understand and agree that I will be required to pay all applicable registration reinstatement fees and fines. If the
motor vehicle liability insurance on my registered vehicle lapses for 91 days or more or is the third (3rd) offense, I understand
and agree that I will be required to pay all applicable registration reinstatement fees and fines, and I will be required to maintain
a Certificate of Financial Responsibility (SR-22 High Risk Insurance) for a period of not less than three years from the
registration reinstatement date. Additionally, if there is a third or subsequent lapse of vehicle liability insurance on the registered
vehicle, I understand and agree that my driver’s license will be suspended for not less than 30 days; I will be required to pay all
applicable registration and driver’s license reinstatement fees and or fines; and I will be required to maintain a Certificate of
Financial Responsibility (SR-22) for a period of not less than three years from the registration reinstatement date.
NEVADA LIVE REINSTATEMENT REQUIREMENTS
Length of lapse
1-30 Days
31-90 Days
91-180 Days
1
st
Offense
TOTAL Fee and Fine
$251
$501
$751 and SR22
2
nd
Offense within the past five years
TOTAL Fee and Fine
$501
$1,001
$1,001 and SR22
3
rd
Offense within the past five years
Driver’s License
Suspension
Minimum 30 Days
Minimum 30 Days
Minimum 30 Days
TOTAL Fee and Fine
$751 and SR22
$1,251 and SR22
$1,501 and SR22
NOTE: a $1 technology has been associated to all fee and fine estimates.
Vehicle Identification Number
Year
Make
Model
Full Legal Name
First
Middle
Last
Nevada Driver’s License, Identification Card Number, or Date of Birth
Physical Address
Address
City
State
Zip Code
Mailing Address
Address
City
State
Zip Code
Telephone
E-mail
NOTE: It is a gross misdemeanor to use a false or fictitious name or address in this application for registration, or to
knowingly make a false statement or knowingly conceal a material fact or otherwise commit a fraud in this application.
Signature
Date
Registered Owner (or authorized person with POA)
State of
County of
Signed and sworn to before me on
by
Date
Name of person making statement
Notary Stamp
Notary Public or Authorized DMV Representative
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DECLARATION OF RESPONSIBILITY (Department of Motor Vehicles )

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Completed 24 December 2020

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