I hereby grant...

Full Name: _______________________________________

Street: ___________________________________________

Suite/Apt: ________________________________________

City: ____________________________________________

State: ___________________________________________

ZIP Code: ________________________________________

Drivers License Number/State: _________________

...to release my vehicle from impound.
 

The person described above assumes financial responsibility for any charges against the vehicle.

Subscribed and sworn to me this _________Day of________________, 20____ .


Signature of Vehicle Owner:_______________________       Date:______________





Signature:____________________________________

                                           (Notary)

My commission expires:________________________.