Fillable Relief Agency or Shelter Certification (Department of Motor Vehicles )

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Relief Agency or Shelter Certification (Department of Motor Vehicles )

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(DMV-115, 8/13)
Relief Agency or Shelter Certification
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/ID Number
Social Security Number (not required for a DAC)
Nevada Relief Agency or Shelter Information
Organization Name
Organization Address
City
State
NV
Zip
Contact Person Name
Telephone Number
Tax ID Number
Tax-ID Exempt
□
I certify that the above-named individual is a resident of Nevada receiving social services from the organization named on this
certification.
Nevada Relief Agency or Shelter Authorized Signature Date
DISCLOSURE STATEMENT: The Privacy Act as passed by the United States Congress authorizes the use of your Social Security number
for the purpose of verifying your identity. This number must be provided and will be used in the administration of driver license laws as
required by NRS 483.290.
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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Relief Agency or Shelter Certification (Department of Motor Vehicles )

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Completed 24 December 2020

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