Fillable Property Owner Residency Affidavit (Department of Motor Vehicles )

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Property Owner Residency Affidavit (Department of Motor Vehicles )

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(DMV-116, 7/13)
Property Owner Residency Affidavit
This certification is used to support a claim that you are a Nevada resident. You must be a resident of Nevada to be
eligible for a driver’s license, driver authorization card (DAC) or identification card (NRS 483.250 (7), 483.290 (5)(b),
and 483.934). The definition of “resident” is found in NRS 483.141.
Th
is certification will be accepted as one form of evidence for your principal residence address.
Customer Information
Name
Residence Address
City
State
NV
Zip
Mailing Address if different
City
State
NV
Zip
DL/DAC/ID Number
Social Security Number (Not required for a DAC)
Property Owner Information
Name
Residence Address
City
State
NV
Zip
Mailing Address if different
City
State
NV
Zip
Choose ONE
:
I certify that the above-named individual maintains a primary residence at my home without a rental or lease agreement.
I certify that the above-named individual has maintained a primary residence on the property I own as shown above for at
least 60 days and entered into a rental/lease agreement with me for this residence on ____________________________.
Date
Property Owner Signature Date
DISCLOSURE STATEMENT: The Privacy Act of 1974 authorizes use of your Social Security Number to verify identity. You are required to
submit your Social Security Number so that the state may administer laws related to licensing drivers (NRS 483.290).
(Not required for a DAC)
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 license or identification card under NRS 483.420
and NRS 483.530, respectively. 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.
Applicant Signature Date
Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas Area (702) 486-4DMV (4368)
Fax: (775) 684-4992
Website: dmvnv.com
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Property Owner Residency Affidavit (Department of Motor Vehicles )

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Completed 24 December 2020

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