Last Use Statement
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
This form can be faxed to (651) 797-1299. You may also bring this form to any Driver Exam Station (Visit the DVS Website
for all Office Locations) or mail this form to Driver and Vehicle Services, Ignition Interlock Unit, 445 Minnesota Street,
Suite 177, St. Paul, Minnesota 55101. For questions, contact DVS at (651) 296-2948 or visit dvs.dps.mn.gov.
- - - -
Date of Birth
Driver's License Number
City/State/Zip
Address
First Name Middle Name Last Name
Daytime Phone Number
1.
4.
2.
6.
5.
3.
I attest that I last consumed any drink or product containing alcohol or controlled
substances on:
Abstinence Date
x
x
x
x
x
x
Signature
Signature
Signature
Signature
Signature
Signature
I acknowledge that I may not operate a motor vehicle until I am informed by the Minnesota
Department of Public Safety that my driving privilege has been reinstated full or conditionally
or I have been issued a limited license (if eligible).
I acknowledge that all of the documents I have submitted become the property of the
Minnesota Department of Public Safety.
I acknowledge that my driver's license will contain a restriction that I may not consume any
drink or product containing alcohol or controlled substances at any time. This restriction is
subject to removal in accordance with M.S. 171.09.
I acknowledge that to maintain my privilege to drive and while my driver's license contains
the abstaining restriction, I may not consume any drink or product containing alcohol or
controlled substances, even when not operating or in physical control of a motor vehicle.
I acknowledge that the Commissioner of the Minnesota Department Public Safety will cancel
and deny my privilege to drive if there is sufficient cause to believe that, after the abstinence
date I have attested to above, I have consumed any drink or product containing alcohol or
controlled substances.
MY COMISSION EXPIRES:
COUNTY:
NOTARY PUBLIC:
_______ day of______20 ________
Subscribed and sworn to before me this
PS31083-14 (09/12)
Any information supplied on this form is required by Minnesota Statutes, Chapter 171, & Minnesota Rule 7503. You may refuse to provide this
information. However, if you do, your driving privilege will be denied. The information will be used by authorized Driver and Vehicle Services
Division personnel. It will be used to determine your eligibility for a Minnesota Driver License or driving privilege in this state.
Signatures must be witnessed by a Notary Public or representative of the Department of Public Safety:
Witnessed by:
Date:
Representative of DPS Notary Public
