Fillable Driver Services Department (Illinois Secretary of State)

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Driver Services Department (Illinois Secretary of State)

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BROWSE ILLINOIS SECRETARY OF STATE FORMS

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Printed by authority of the State of Illinois. August 2019 - 1 - DSD DC 164.13
All requestors must complete Sections I, II, IV and V.
SECTION I
Enter the driver’s license number and/or the name and date of birth of the driver(s) whose record(s) is being requested in the spaces
below. PLEASE PRINT LEGIBLY.
DRIVER’S LICENSE NUMBER NAME (Last, First, Middle) DATE OF BIRTH GENDER
______________________________________
____________________________________ ____________________ ____________
______________________________________
____________________________________ ____________________ ____________
______________________________________
____________________________________ ____________________ ____________
______________________________________
____________________________________ ____________________ ____________
______________________________________
____________________________________ ____________________ ____________
SECTION II – REQUESTOR’S IDENTITY
Driver’s license, permit or ID number: _____________________________________________________________________________
For yourself: ☐ Yes ☐ No (If no, complete Section III.)
SECTION III – If you classified yourself as a representative or agent of anyone other than yourself in Section II, you must provide
the following information. Complete Section IV on reverse.
If the record(s) you requested must be mailed, to which address above should it be mailed: ☐ Section II ☐ Section III
SECTION IV (Please see reverse.)
SECTION V – AFFIRMATION OF REQUESTOR
I affirm that the information in Sections I, II, III and IV are true and correct to the best of my knowledge. I understand that if any
of the information provided by me in these sections is knowingly false or misleading, administrative, civil and/or criminal actions
may be taken against me. (Notarization required if mailing form.)
Notary Seal
Signature: ____________________________________ Date:
____________________
SECRETARY OF STATE USE ONLY
Identification checked:
______________________________________________________________________________________________________
Employee signature: ______________________________________________________ Date: ________ - ________ - ________
Number of certified records: ________ x $12.00 = ________ Type of record: __________________________________________
Number of photocopies: (Springfield only) _______ x $ .50 = ______ Cash MO Check Credit Card
Number of certifications: (Springfield only) ______ x $2.00 = ______
Name First M.I. Last
________________________________________________________________________________________________________________________________
Residential Address Phone number
________________________________________________________________________________________________________________________________
City State ZIP
Name of person or organization I am representing
________________________________________________________________________________________________________________________________
Address of person or organization
________________________________________________________________________________________________________________________________
City State ZIP
Driving Record Abstract Request Form
Office of the Secretary of State
Driver Services Department
DRIVER’S ANALYSIS
2701 S. DIRKSEN PKWY.
SPRINGFIELD, IL 62723
217-782-2720
www.cyberdriveillinois.com
If you are purchasing your own certified driving record, you may do so by using the online Driving Record Abstract system at
www.cyberdriveillinois.com.
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SECTION IV
Place an “X” in front of the category below that describes you concerning the record(s). Mark only one category per request form.
Items within ( ) are for Secretary of State personnel.
Purpose of Request (This information must be provided if you mark a box that has an asterisk next to it.): ____________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I AM:
*
■
the person named on the abstract requested. (AFF or PUB-FEE “S”)
*
■
a law enforcement or court official with an official need for the abstract(s) requested. Complete Section III. (CRT or EXT-NO
FEE “L”)
*
■
a private investigative agency or security service licensed in Illinois for any purpose permitted under 625 ILCS 5/2-123 of the
Illinois Vehicle Code. Complete Section III. (PUB-FEE-”H”)
Detective State Registration #: _____________________
*
■
the legal representative of the person(s) named on the abstract(s) requested. Complete Section III. (AFF or PUB-FEE-”R”)
Attorney State Registration #: __________________________________________
■
an attorney not representing the person(s) named on the abstract(s) requested but needing the abstract(s) for legal business
involving the affected driver(s). Complete Section III. (PUB-FEE-”A”)
Attorney State Registration #: ______________________________________
*
■
the parent/legal guardian of the minor person(s) (under age 18) named on the abstract(s) requested. I am submitting the
minor’s signed and notarized consent to obtain his/her abstract. (AFF or PUB-FEE-”P”)
■
an immediate family member (parent/legal guardian, brother, sister, spouse, grandparent, child or grandchild) of the adult (age
18 or older) named on the abstract(s) requested. I am submitting the adult’s signed and notarized consent to obtain his/her
abstract. (PUB-FEE-”F”)
Relationship: _________________________________________
■
a representative of a local, state or federal government agency, with an official business need for the abstract(s) requested to
carry out the agency function on this request form. Complete Section III. (EXT-NO FEE-”G”)
If an elected official, office held: _________________________________________________
■
a representative of the insurance industry with a legitimate insurance business need for the abstract(s) requested. Complete
Section III. (PUB-FEE-”I”)
■
the employer, prospective employer, or representative of the employer or prospective employer of the person(s) named on the
abstract(s) requested. I am submitting the employee’s signed and dated consent form. If I am coming into a facility, I will
bring in the employees signed and dated consent form. The abstract(s) is needed for business purposes pertaining to the
person’s(s’) employment or prospective employment. Complete Section III. (PUB-FEE-”E”)
■
a representative of a financial institution with a legitimate business need for the abstract(s) requested. Complete Section III.
(PUB-FEE-”B”)
■
a representative of a new or used vehicle dealership, vehicle rental agency, or tow truck operation with a legitimate business
need for the abstract(s) requested. Complete Section III. (PUB-FEE-”D”)
■
none of the above. The abstract(s) requested will be mailed to you by the Secretary of State Driver Services Department in
Springfield in approximately 10 business days. The Secretary of State’s office will send a letter to each person for whom a driving
abstract is requested approximately 10 days prior to mailing his/her abstract(s) to you. The letter will inform the person(s) of
the date of your purchase and your name. NOTE: The abstract(s) requested will not list the address or personal information
of the individual(s). (PUB-Fee ”N”)
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Driver Services Department (Illinois Secretary of State)

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Completed 13 November 2020

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