
TRANSMITTAL FORM
Applicant—Complete Only Sections That Apply
NAME (FIRST, MIDDLE, LAST) DL or ID NUMBER SOCIAL SECURITY NUMBER
ADDRESS CITY STATE ZIP CODE DAYTIME AND EVENING TELEPHONE NUMBER
( ) ( )
Emancipated Minor
(Driver License)
I am an unmarried minor. I am declaring myself emancipated because:
_________________________________________________________________________________
I am also submitting Proof of Financial Responsibility (SR 1P) in lieu of a guarantor’s signature.
My parents are:
deceased.
nonresidents of California.
living (one or both) and are California residents.
Other
NAME OF PARENT (FIRST, MIDDLE, LAST) ADDRESS CITY STATE ZIP
NAME OF PARENT (FIRST, MIDDLE, LAST) ADDRESS CITY STATE ZIP
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is
true and correct.
DATE NAME OF PARENT (FIRST, MIDDLE, LAST) SIGNATURE
X
Emancipated Minor
(ID Card)
Please issue an identication card to me marked with the word “EMANCIPATED” because:
I have entered into a valid marriage. (Civil Code Section 62)
I am on active duty in the Armed Forces. (Civil Code Section 62)
of a Declaration of Emancipation. (Family Code Sections 7120—7123)
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is
true and correct.
DATE NAME OF PARENT (FIRST, MIDDLE, LAST) SIGNATURE
X
Consent for
Issuance
(Parents Not
Accepting
Civil Liability)
I am the _____________________________of ___________________________________________
RELATIONSHIP NAME OF MINOR
and, as such, a person required to sign and verify a minor’s application for a driver license. I consent to
the issuance of a driver license to this minor provided the minor’s application is accompanied by proof of
nancial responsibility as dened by the California Vehicle Code (CVC). I do not consent to accept the
civil liability specied in CVC §17707 and §17708.
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is
true and correct.
DATE NAME OF PARENT (FIRST, MIDDLE, LAST) SIGNATURE
X
Acceptance of
Liability For Minor
(Dependent or
ward of the court)
This minor resides with me and my relationship to this minor is _____________________________
• Iamage18oroverandaresidentofCalifornia,
• Thisminorisadependentorwardofthecourt,
• Iconsenttotheissuanceofanoriginalorduplicatedriverlicensetothisminor,
• IassumetheliabilityspeciedinCaliforniaVehicleCode§17707through§17710.
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is
true and correct.
DATE NAME OF PARENT (FIRST, MIDDLE, LAST) SIGNATURE
X
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DL 11 (REV. 8/2009) WWW