An Arizona Management System Agency

ARIZONA DEPARTMENT OF TRANSPORTATION 1801 W. Jefferson St. | Phoenix, AZ 85007 | azdot.gov

Motor Vehicle Division Douglas A. Ducey, Governor John S. Halikowski, Director

Eric R. Jorgensen, Division Director

Mon. Day, Year

Dear :

I, , RACF, herby notify COMPANY NAME (Fillable) that my driver license has one or more of the following offenses: (check all that apply)

Driver license is suspended, revoked, cancelled or disqualified by the Department

Vehicle certificate of title is canceled by the Department; or

Vehicle registration is suspended or canceled by the Department;

Date of notice:

Pursuant to Arizona Administrative Code (A.A.C.) R17-7-303, a certified individual shall provide notification within 24 hours to the Authorized Third Party.

Additional information may be required following the review of this notice. You must attach with this form, your Motor Vehicle Record(s) (MVR). The MVR must be dated within 30 days of the date of this notice being submitted.

Electronic Submission Instructions: 1) Complete form entirely. 2) Press submit button. 3) An e-mail will generate. 4) Do not change the wording of the e-mail. 5) Attach supporting documentation to the e-mail. 6) Email Recipient must be your Third Party Manager/Supervisor. 7) Press send.

56-0114 R07/18