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CERTIFICATION FOR PURCHASE OF REPORT BY MAIL <br /> Please complete the below and attach to your written request for a report copy. <br /> I certify that I am a party of proper interest under Vehicle Code Section 20012 <br /> Check one: ❑Driver ❑Passenger I_]Owner ❑Family member ❑Pedestrian <br /> REQUESTER'S NAME(PRINT) SIGNATURE <br /> STREET ADDRESS <br /> CITY,STATE AND ZIP CODE <br /> FINANCIAL RESPONSIBILITY INFORMATION <br /> California's Financial Responsibility Law requires you to report to the Department of Motor <br /> Vehicles(DMV)any traffic accident which results in damage to the property of any person in <br /> excess of$750 or in bodily injury or death. Use Form SR-1 which is available at all CHP and <br /> DMV offices. Law enforcement reports do not satisfy the DMV report requirement. Failure to <br /> submit the Form SR-1 to DMV may lead to the suspension of your driving privilege. <br />