DR 2100 (08/31/16)
COLORADO DEPARTMENT OF REVENUE
Division of Motor Vehicles
Driver Control Section, Room 164
PO Box 173350
Denver, CO 80217-3350
Release From Liability
I (we) release the following person from all claims or liability as a result of the motor
vehicle accident shown below. This release satises the requirements of the Financial
Responsibility Act §42-7-301, C.R.S.
FR Case Number
Date of Accident
Name of Person Released from Liability Driver's License Number Date of Birth
Address City State ZIP
Names of other person(s) involved in this accident having injuries or property damage.
1.
Name
Address City State ZIP
2.
Name
Address City State ZIP
3.
Name
Address City State ZIP
Signatures
No. 1 Date
No. 2 Date
No. 3 Date
Signature of Parent or Guardian of Minor Date
Seal
Subscribed and afrmed, or sworn to, before me this ______ day of
_____________________ , 20____
in the County of _____________________, State of ________________________.
Notary Signature
Commission Expiration Date
