4 4 4 4 DIVISION OF MOTORIST SERVICES 2900 Apalachee Parkway Neil Kirkman Building Tallahassee FL 32399 CERTIFICATION OF ADDRESS Date I do hereby certify that Name First Middle Last Dat e ID: 231048
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4 4 4 4 DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES DIVISION OF MOTORIST SERVICES 2900 Apalachee Parkway Neil Kirkman Building - Tallahassee, FL 32399 CERTIFICATION OF ADDRESS Date I do hereby certify that : Name (First) (Middle) (Last) Dat e of Birth Resides at : Street, Apartment City State Zip Code SPECIAL CONDITIONS: Self Certification Released from Incarceration** Other Signature of Addressee/Customer Print Name of Addressee/Customer Date INSTRUCTIONS : A Certification of Address form completed and signed by the customer is accepted as proof of residential address, providing it is accompanied by: o One proof of residen tial address in the customer’s name or; o One proof of residential address in the name of the person with whom the customer resides. *** * Homeless customers may represent ative along with the completed Certification of Address form. ** Customers released from incarceration may present an Address Verification Letter from the Department of Corrections ( with an Inmate Identification Card and Certificate of Discharge ) along w ith the completed Certification of Address form . *** A list of documents that can be used as proof of residential address can be found at www. G ather G o G et.com . HSMV 71120 (Rev 0 4 /13 ) 04/02/2013 Carol Owens 33619 Florida Tampa 10137 E Adamo Drive, Suite 800A 01/01/1997 Owens Carol 04/02/2013 1