555 Wright Way
Carson City, NV 89711
Reno/Carson City (775) 684-4DMV (4368)
Las Vegas (702) 486-4DMV (4368)
dmv.nv.gov
DMV-128 (04/2024)
Signatures must be originals. Photocopies are not acceptable.
Changes may not be made to this form once it is signed.
Page 1 of 1
DECLARATION OF HOMELESS STATUS
NRS 193.130 & NRS 483.410 to 483.825
This form must be submitted along with the DMV-002 (Application for Driving Privileges or ID Card).
LAST NAME (Please Print)
FIRST NAME
MIDDLE NAME
ADDRESS WHERE I AM STAYING
CITY
STATE
ZIP CODE
25 AND OLDER
UNDER 25
NRS 483.417 AND NRS 483.825
NRS 483.410 AND NRS 483.820
I am requesting an/a Duplicate:
I am requesting an/a:
☐
Non-Commercial Driver’s License
☐
Original
☐
Duplicate
☐
Renewal
☐
Instruction Permit
(Choose one)
☐
Identification Card
☐
Non-Commercial Driver’s License
☐
Driver Authorization Card
Fees will be waived one time only and you
must reimburse the Department the cost of the
photo fee when you renew your card, if
employed at that time.
☐
Instruction Permit
All fees for this issuance will be waived one time only
and are not required to be reimbursed at any time.
UNDER 25
NRS 483.825 AND NRS 483.820
I am requesting an/a:
☐
Identification Card
☐
Original
☐
Duplicate
☐
Renewal
☐
Change
All fees for this issuance will be waived and are not required to be reimbursed at any time.
I hereby certify under penalty of perjury that all statements in this application are true and correct. I
agree and understand that any misstatement of material facts may cause cancellation and/or denial
of my driver’s license, instruction permit or identification card under NRS 483.420 and 483.530. I
further understand that any misstatement of facts may be a misdemeanor or felony under NRS
483.530 and may be punishable pursuant to NRS 193.130.
SIGNATURE OF APPLICANT
DATE