Operator Church

SR-** FINANCIAL RESPONSIBILITY FORM

Insured's Name: HAROLD CHATMAN

Insured's Address:3258 BRICK CHURCH PIKE APT 129 NASHVILLE, TN 37207 Case No. Driver's License No. Birth Date Social Security No. 059******-**/01/1961 ***-**-****

Current Policy # 15-42-001****-** Effective From 02/24/2018 to 08/24/2018 This certification is effective from 02/24/2018 and continues until cancelled or terminated in accordance with the financial responsibility laws and regulations of Tennessee. The insurance hereby certified is provided by an: OWNER'S POLICY: Applicable to (a) the following described vehicle(s), (b) any replacement(s) thereof by similar classification, and (c) any additionally acquired vehicles of similar classification for a period of at least 30 days from the date of acquisition.

Model year Trade Name Identification No.

2013 Nissan Sentra3N1AB7AP7DL663628

OPERATOR'S POLICY: Applicable to any non-owned vehicle. FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE

The company signatory hereto hereby certifies that it has issued to the above named insured a motor vehicle liability policy as required by the financial responsibility laws of Tennessee, which policy is in effect on the effective date of this certificate.

Lyndon Southern Insurance Company NAIC 10051

Name of Insurance Company

02/24/2018

Date Signature of Authorized Representative

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