TWENTY-FOUR HOUR AFFIDAVIT X

BMV 5789 7/18 [760-1073]

OHIO DEPARTMENT OF PUBLIC SAFETY

TWENTY-FOUR HOUR AFFIDAVIT

PLEASE PRINT

NAME OF TEMPORARY PERMIT HOLDER

TEMPORARY INSTRUCTION PERMIT I.D. #

ADDRESS

CITY

STATE

ZIP CODE

E-MAIL ADDRESS OR TELEPHONE #

NAME OF LICENSED DRIVER(S)

DRIVER LICENSE #

The above named temporary permit holder personally appeared before me, and has duly sworn to have completed twenty-

four (24) hours of driving with a valid licensed driver without exceeding four (4) hours of driving per day.

SIGNATURE OF TEMPORARY PERMIT HOLDER

DATE

Notary:

Sworn to and subscribed in my presence this day of , 20 in County,

State of .

(Notary Seal)

Signature of Notary Public X My commission expires

NOTICE: Falsifying an affidavit is punishable by fine and / or imprisonment (Ohio Revised Code Section 2921.11).