HTML Preview Property Damage Release Form Sample page number 1.
HSMV 74014 (Revised 06/13)
Florida DHSMV
Release Form for Property Damage/Injury
SUSPENDED DRIVER’S PERSONAL INFORMATION (Please Print):
Last Name
First Name
Middle
Initial
Suffix
Social Security Number
Current Mailing Address
City
State
Zip Code
Date of Crash
Date of Birth (MM/DD/YY)
Driver’s License Number
Location of Crash
Financial Responsibility Case Number
Date of Full Release
Terms of Release: I/We do hereby release and forever discharge the party named above, from any and all claims and demands for damage,
injury or loss, arising out of the above listed crash. This release includes all future and unforeseen and unanticipated injuries, damages, loss
and liability, as well as those now known to exist. It is further agreed that this payment is not an admission of any liability.
Signatures Below Must Be Notarized: (Other party or representatives to other party choose applicable option below)
1. Other Party Name (print):
Signature:
2. Signing on behalf of name (for insurance company, attorney, subrogee
of, etc.):
Signature:
Title of Position (for insurance company, attorney, etc.):
Notary Name: Name of other party or representative:
State of:
County of:
The foregoing instrument was acknowledged before me this ______ day of ______________________, 20____
by__________________, who is personally known to me or who produced a/an __________________ as identification and who
did (did not) take an oath.
Affix seal here Notary Public Signature:
Note: Release is VOID unless all signatures are notarized. Please retain a copy of this completed form for your
records.
Return to:
Department of Highway Safety and Motor Vehicles Phone: 850-617-2000
Bureau of Motorist Compliance, MS 98 Fax: 850-617-5216
Post Office Box 5775
Tallahassee, Florida 32314-5775 DHSMV Web Site: http//www.flhsmv.gov