Free MV3216 - Wisconsin


File Size: 27.9 kB
Pages: 1
Date: February 20, 2009
File Format: PDF
State: Wisconsin
Category: Government
Author: WisDOT
Word Count: 348 Words, 2,212 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dot.wisconsin.gov/drivers/forms/mv3216.pdf

Download MV3216 ( 27.9 kB)


Preview MV3216
SECURITY DEPOSIT ASSIGNMENT
MV3216 2/2009 s.344.20 Wis. Stats. Please print clearly. Accident Date Depositor Name Depositor Mailing Address City, State, ZIP Code

Clear Form

To:

Wisconsin Department of Transportation Uninsured Motorist Unit PO Box 7983 Madison, WI 53707-7983

File No. SRSecurity Amount Assigned

$
Assigned To Mailing Address City, State, ZIP Code

I, the depositor, assign the above sum to the claimant / releasing party from the security deposited as a result of this accident. I further specify that the balance of the deposit (if any), shall be returned to me at the above address. In consideration of this assignment, the uninsured driver and uninsured owner are furnished with a release of liability signed by the claimant / releasing party on the bottom of this form.

X
(Depositor) (Date) State of Wisconsin County ) ) ss. ) (Date)

On the above date, this instrument was acknowledged before me by the named person(s).

(Signature, Notary Public, State of Wisconsin) (Print or Type Name, Notary Public, State of Wisconsin) (Date Commission Expires) Releasing party: Complete below.

LIABILITY RELEASE
Please print clearly. Uninsured DRIVER Name and Address Uninsured OWNER Name and Address Release Amount Accident Date

For and in consideration of the "Release Amount" to be paid to me from the security deposit assigned on the top of this form, the undersigned does release and forever discharge the above uninsured driver and uninsured owner of all claims and causes of action resulting from this accident. It is also understood that this release discharges all liability between the undersigned and the parties named only. The parties expressly reserve the right to pursue other claims or causes of action against all others who are or may be liable in the above accident.

THIS RELEASE MUST BE WITNESSED
(Witness Signature) (Signature)

RELEASING PARTIES
(Date) (Print or Type Name)

(Witness Signature)

(Signature) (Print or Type Name)

(Date)

If court action is on file, a certified copy of the final dismissal must also accompany the assignment and release. Assignment to insurance companies can be honored ONLY when accompanied by a signed subrogation receipt.

Print Form