Fillable RMV - MAB110 Voluntary Surrender Affidavit

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RMV - MAB110 Voluntary Surrender Affidavit

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U.S.A. forms for Commonwealth of Massachusetts

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Voluntary Surrender Affidavit
Medical Affairs ● P.O. Box 55889, Boston, MA 02205-5889
Fax: 857-368-0018
p.1 MAB110_0218
Complete and return to address above. Include original license if you have it. If you don't have the original license,
complete the Lost License Affirmation section below. Upon surrendering your license for medical reasons, you can
receive a Massachusetts ID card for no fee.
A. Driver Information
(Required)
Last Name
First Name
Middle Name
Suffix
Date of Birth (MM/DD/YYYY)
License #
I voluntarily surrender my license. In order to restore my driving privileges, I will need to present medical clearance to
the
Registry of Motor Vehicles.
Signature: ________________________________________________________________________________________
Date: _________________________________
B. Lost License Affirmation
I swear and affirm under the penalties of perjury that I am no longer in possession of the license issued to me by the
Massachusetts Registry of Motor Vehicles.
False statements made hereunder may be punishable by fines, imprisonment, or both. (M.G.L. Chapter 90, Section 24).
Signature: _______________________________________________________________________________________
Date: _________________________________
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RMV - MAB110 Voluntary Surrender Affidavit

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Completed 12 May 2020

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