PDF NOTICE: RESTRICTED - Ohio Department of Public Safety
PLEASE PRINT
NAME OF TEMPORARY PERMIT HOLDER
OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES
FIFTY HOUR AFFIDAVIT
TEMPORARY INSTRUCTION PERMIT I.D. #
ADDRESS
CITY
STATE
ZIP CODE
NAME OF PARENT, GUARDIAN, OR CUSTODIAN
DRIVER LICENSE / I.D. CARD #
RELATIONSHIP TO TEMPORARY PERMIT HOLDER
ADDRESS
CITY
STATE
ZIP CODE
E-MAIL ADDRESS OR TELEPHONE #
The above named parent, guardian or custodian personally appeared before me, and has duly sworn that the above named temporary permit holder (under the age of 18) has completed fifty (50) hours of driving including a minimum of ten (10) hours of driving at night between one-half hour after sunset and one-half hour before sunrise.
SIGNATURE OF PARENT, GUARDIAN OR CUSTODIAN
X
Sworn to and subscribed in my presence this
day of
, 20
in
County,
State of
.
(Notary Seal)
Signature of Notary Public X
My commission expires
NOTICE: Falsifying an affidavit is punishable by fine and / or imprisonment (R.C. Section 2921.21 and 4507.21[G]).
BMV 5791 4/16 [760-1073]
RESTRICTED
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