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TENNESSEE DEPARTMENT OF SAFETY

AND HOMELAND SECURITY

MINOR/TEENAGE AFFIDAVIT AND CANCELLATION

Minor/Teenage Affidavit
I, the undersigned, make oath in due form of law that I am the _____________________________________
(Relationship)
of ____________________________________________________________________________________,
(Full Name of Applicant)

Social Security Number: __________________________ Date of Birth: ________________________ and


(Month/Day/Year)
I hereby join in application of said applicant for a Tennessee Driver License / Photo Identification License.
(Circle One)

For Parent/Legal Guardian of Teenage Applicants for Driver License Only:


I hereby accept all of the responsibilities and obligations imposed under the provisions of Tennessee Annotated
Code Annotated 55-50-311 and 312 as the parent/legal guardian of said applicant, who is under eighteen (18)
years of age, and I fully understand and agree that any negligence or willful misconduct of the said applicant
while operating a motor vehicle prior to his/her eighteenth (18th) birthday shall be imputed to me and I shall be
jointly and severally liable for any damages caused by him/her while operating a motor vehicle.

Cancellation of Teenage Affidavit


I, the undersigned, state I signed the application of ________________________________________________
(Full Name of Applicant)

Social Security: __________________________ Driver License Number: ____________________________

Date of Birth: __________________________________ and now desire to be relinquished of all responsibilities


(Month/Day/Year)

and obligations imputed to me and I shall not be liable for any damages caused by him/her should they operate a
motor vehicle. Therefore, I hereby request his/her license be cancelled.

Affiant’s Official Signature:

___________________________________________________________________________________________
Parent/Legal Guardian Driver License Number Driver License State Social Security No.

Legal Residence:

___________________________________________________________________________________________
House, Street, and Apartment Number CITY STATE ZIP CODE

Sworn to, or affirmed, before me and subscribed in my presence this the _________ day of
_________________________

20________.
NOTARY PUBLIC
OR EXAMINER _________________________________________
My Commission expires the ____________ day of _______________________ 20_______.

Page 1 of 2

SF-0259 (REV 10/15) RDA 1415


Summary of Tennessee Financial Responsibility Law
Tennessee Code Annotated, Title 55
The law requires that you be advised of your obligations and how this law may affect your driving and vehicle
registration privileges. The purpose of the law is to protect you and the public from financially irresponsible
drivers who become involved in an accident, as well as from drivers who have repeated violations and disregard
of the law.

Liability insurance provides coverage for damages you cause to other persons. Uninsured motorist
insurance provides coverage for the damages uninsured persons cause you. State law requires your agent to
offer you coverage against uninsured drivers.

1. IF YOU CONTRIBUTE TO A REPORTABLE ACCIDENT you may be required to establish financial


responsibility for that accident. If so, you will be required to file an accident report with the Department
of Safety and Homeland Security. You will have to do one of these three (3) things when you file your
report: (1) show proof you had liability insurance at the time of the accident; (2) obtain notarized
releases from all parties that file claims with the department; (3) post cash or corporate security bond
with the department for the amount of damages sustained by the other parties. IF YOU DO NOT
COMPLY WITH ONE OF THESE REQUIREMENTS YOU WILL HAVE YOUR DRIVING AND
REGISTRATION PRIVILEGES REVOKED.

2. THE FINANCIAL RESPONSIBILITY LAW requires officers to ask drivers for proof of financial
responsibility when they are charged with moving violations or involved in traffic accidents. Proof of
financial responsibility is: evidence of liability insurance in effect at the time of the violation or
accident; proof the driver has qualified as a self-insurer with the Department of Safety and Homeland
Security; or proof the driver has posted a bond with the Department of Safety and Homeland Security.
If convicted of failure to have such proof in the vehicle, the driver may be fined $100.00 and the driver
license will be suspended.

3. IF YOU DO NOT TURN IN A DRIVER LICENSE, VEHICLE LICENSE PLATE, OR VEHICLE


REGISTRATION WITHIN 20 DAYS when any is revoked, suspended or canceled, you will owe the
department a $75.00 fee in addition to other required reinstatement fees.

4. IF YOUR DRIVING PRIVILEGES ARE REVOKED DUE TO A CONVICTION OR FAILURE TO


FILE SECURITY AFTER AN ACCIDENT, in addition to all other requirements, you must have a
liability insurance carrier file an SR-22 form with this department before your privileges can be
reinstated.

Questions regarding Tennessee’s Financial Responsibility Law should be directed to: Tennessee
Department of Safety and Homeland Security, P.O. Box 945, Nashville TN 37202; telephone number Toll-
Free 1-866-903-7357

AFFIDAVIT OF APPLICANT:
“I CERTIFY THAT I UNDERSTAND TENNESSEE’S FINANCIAL RESPONSIBILITY LAW AS SET
FORTH IN TENNESSEE CODE ANNOTATED, TITLE 55 AND I AGREE TO ABIDE BY IT”

Signature of Applicant ____________________________________________ Date:__________________

Parent’s Signature ________________________________________________ Date:__________________


Parent’s Signature (if Applicant is under Age 18)

Page 2 of 2

SF-0259 (REV 10/15) RDA 1415

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