DMV 005 Certification of Nevada Residency - …

1 Reno/Sparks/Carson City (775) 684-4 DMV (4368). Las Vegas Area (702) 486-4 DMV (4368). Rural Nevada (877) 368-7828. Fax: (775) 684-4992. Website: Certification of Nevada Residency This Certification is used to support a claim that you are a Nevada resident. You must be a resident of Nevada to be eligible for a Driver's License (DL), Driver Authorization Card (DAC) or Identification Card (ID) [NRS (7), (5)(b), and ]. The definition of resident is found in NRS Customer Information 0B. Name Residential Address City State Zip Mailing Address if different City State Zip DL/DAC/ID Number Social Security Number (not required for a DAC). This form and one of the following documents must be submitted to show proof of Nevada Residency . ORIGINAL OR CERTIFIED COPY ORIGINAL OR CERTIFIED COPY OF.

2 DATED WITHIN 60 DAYS LAST ISSUED DOCUMENT. Receipt for rent of a residential address A property tax record, lease, rental A record from a public utility for residential service agreement, mortgage document or deed of A bank or credit card statement a Nevada residence A paycheck stub Enrollment records from a Nevada A document from a state or federal court educational institution A record, receipt or bill requesting payment A vehicle liability insurance card, binder or Motel, hotel, campground or recreational vehicle park receipts showing that you bill issued by a Nevada -based carrier have been residing in Nevada for at least 30 consecutive days (cannot be handwritten). A Nevada Voter registration card issued pursuant to NRS Confidential Address Program (CAP).

3 A document showing receipt of public assistance or benefits from a State of documents issued pursuant to NRS. Nevada agency to , inclusive Military Leave and Earnings Statement (LES) to evidence Nevada Residency of Tax records other than property taxes applicant deployed outside of Nevada while serving on active duty A student identification card from a Nevada educational institution Form DMV115 - Relief Agency or Shelter Certification Form DMV116 - Property Owner Residency Affidavit DISCLOSURE STATEMENT: The Privacy Act as passed by the United States Congress authorizes the use of your Social Security number for the purpose of verifying your identity. This number must be provided and will be used in the administration of driver's license laws as required by NRS (This is not required for a DAC.)

4 I hereby certify under penalty of perjury that all statements in this application are true and correct. I agree and understand that any misstatement of material facts may cause cancellation and/or denial of my driver's license or identification card under NRS. and NRS , respectively. I further understand that any misstatement of facts may be a misdemeanor or felony under NRS and may be punishable pursuant to NRS Applicant's Signature Date IF the applicant is not able to produce one of the above required documents in his or her name, this Certification must be signed by a second resident living at the same residential address. The applicant must present proof of Residency showing the second resident's name and residential address in the form of one document listed above.

5 The second resident does not need to accompany the applicant to the DMV. Signature of Second Resident Attesting to Nevada Residency Driver's License or Identification Card No. DMV-005 (Rev. 1/2014).