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Affidavit of Non Responsibility

If a vehicle was stolen or under the care of another individual at the time it was reported for a traffic violation, the vehicle’s legal owner must execute this affidavit to evade the charges.

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AFFIDAVIT  	
 
I,          	, having been sworn, hereby depose and say as follows:  
 	
1.  I have received a Uniform Traffic C itation (UTC) informing me that a motor vehicle 
registered in my name was observed violating Florida Statutes §§ 316.074(1) and 
316.075(1)(c)1 by failing to obey a steady red traffic signal. The UTC bears the following 
13 digit Notice number         	
 and the f ollowing 7 digit UTC 
number	
           	. 
  2. Under Florida Statute § 316.0083(1)(d), I am exempt from the payment of the statutory 
penalty described in the Notice because (check all that apply):  
 
 At the time of the violation described in the UTC, my vehicle passed through the 
intersection in order to yield the right -of -way to an emergency vehicle.  
  At the time of the violation described in the UTC, my vehicle passed through the 
intersection as a part of a funeral procession.  
  At the time of the violation described in the UTC, my vehicle passed through the 
intersection at the direction of a law enforcement officer.  
	
  At the time of the violation described in the UTC, the vehicle was in the care, 
custody, or control of another person. That person’s name, address, and date of birth 
are                                      	
, 
I  do/  	
 do not know the driver’s license number of this person. If known, that 
number is          	
. 
  At the time of the violation described in the UTC, my vehicle had been stolen. A true 
and correct copy of a police report establishing that my vehicle had been stolen at 
that time is attached to this affidavit.  
  A Uniform Traffic Citation has been issued by a law enforcement officer to the driver 
of the vehicle for the same violation of Florida Statutes §§ 316.074(1) and 
316.075(1)(c)1 described in the Notice.   
The serial number of that citation is	
            .	 	
 
3. I understand that Florida Statutes § 316.0083 requires that I provide detailed information 
supporting the exemption(s) I have identified in Paragraph 2, which may include  the 
facts and circumstances supporting the exemption I have asserted. That detailed 
information is as follows (attach additional sheets as necessary):  
                         
                         
                         	 	
 
4. The foregoing statements are true and correct. 
 
                         	 	
Signature of Registered Owner  
 
VERIFICATION OF NOTARY OR PERSON AUTHORIZED TO ADMINISTER OATHS  
STATE OF FLORIDA  
COUNTY OF PINELLAS  	
Sworn to and subscribed before me on 	     	   	, 20 	, by      	 
who is  	
 personally known to me or   provided identification, and who did take an oath.  
 	
                         	 	
              Notary Public, State of Florida or Deputy Clerk 
              Printed Name:        	 
              My Commission Expires:
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