AFFIDAVIT MUST BE COMPLETED IN FULL AND NOTARIZED
STATE OF MINNESOTA
COUNTY OF HENNEPIN
FOURTH JUDICIAL DISTRICT
DRIVER - NON OWNER OF VEHICLE
I, ____________________________ , received Citation No. ____________________
On _____________________ (date) charging no proof of insurance under M.S.
169.791. I further state that I am not the registered owner of said vehicle and that the
true owner of the vehicle is:
This affidavit is made pursuant to MS 169.791. I understand that any false information
given may result in my being charged with a misdemeanor.
Subscribed and sworn to before me
On _________________ , ________
(Month and day)
Court Deputy or Notary Public
AFFIDAVIT MUST BE FILLED OUT COMPLETELY AND NOTARIZED