HomeMy WebLinkAboutParental Consent Form- Fillable_________________________________ ____________
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AFFIDAVIT
STATE OF HAWAII )
CITY AND COUNTY OF HONOLULU )
being first duly sworn.
Deposes and says: [ I am we are] the [ father mother parents guardian(s)] of
born on (FULL LEGAL NAME OF CHILD) (DATE OF BIRTH OF CHILD)
This affidavit has been made in connection with the desire of the aforesaid child to secure a license to drive;
I am We are willing to assume the obligation imposed by Section 286-112(b), HRS, “Any negligence or misconduct of a minor under the age of eighteen years when driving a motor vehicle upon a highway shall be imputed to the person who has signed the application of the minor for a permit, provisional license, or license, which person shall be jointly and severally liable with the minor for any damages caused by the minor’s negligence or misconduct.”
Further Affiant sayeth naught.
Dated: City and County of Honolulu, Hawaii .
SIGNATURE OF MOTHER / GUARDIAN / LEGAL PARENT
PRINTED NAME
IDENTIFICATION PRESENTED EXP. DATE
SIGNATURE OF FATHER / GUARDIAN / LEGAL PARENT
PRINTED NAME
IDENTIFICATION PRESENTED EXP. DATE
SIGNATURE OF EXAMINER DATE
Subscribed and sworn before me this______________day
of _______________________________ , 20 _________ .
Notary Public
State of ___________________ , _______Judicial Circuit
My commission expires: ___________________________
NOTARY CERTIFICATION:
(Hawaii Administrative Rules §5-11-8)
Document Date: _________________ No. Pages: ______
Document Description: ____________________________
Notary Printed Name Circuit
Notary Signature Date
(Stamp or Seal) (Stamp or Seal)
CS-L-(DL) 239 (9/12)-mm