Affidavit of Non Responsibility

This affidavit is to be executed by the affiant who violated traffic rules in the State of Floirda but the vehicle at the time of the incident was stolen or in the care of other person.

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AFFIDAVIT
I, , having been sworn, hereby depose and say as follows:
1. I have received a Uniform Traffic Citation (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 following 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: