MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street, Suite 166
Saint Paul, MN 55101-5166
Phone: (651) 297-5034 FAX: (651) 797-1810 TTY: (651) 282-6555
Request for Administrative Review of License Plate Impoundment Order
MAKE MODEL YEAR VEHICLE IDENTIFICATION NUMBER IMPOUNDED PLATE NUMBER
DRIVER'S FULL NAME AT TIME OF INCIDENT DRIVER'S LICENSE NUMBER
DRIVER'S FULL ADDRESS AT TIME OF INCIDENT
PS31125-14 Rev. 02/16
Purchaser must complete Sections A and C, and sign at X below. Incomplete information may cause transfer to be
delayed or denied.
Signature of Purchaser: X
Except for certain uses permitted by federal and state laws, personal information contained in your application may not be disclosed to anyone without your express consent. You are
advised that information given in this form may be used in any court related action involving your plate impoundment including any criminal charges that may result from this incident.
IMPORTANT NOTICE: PLEASE READ
DATE OF BIRTH
OWNER'S OR PURCHASER'S ADDRESS AT TIME OF INCIDENT
DRIVER'S LICENSE NUMBERDATE OF BIRTHOWNER'S OR PURCHASER'S FULL NAME
OWNER'S OR PURCHASER'S CURRENT ADDRESS (if different from address at the time of incident)
REQUEST FOR ADMINISTRATIVE REVIEW BY THE VEHICLE OWNER WHO WAS NOT THE VIOLATOR/OPERATOR
It is important that you include all the required information when you request the review. You are entitled to only one
administrative review. Complete Sections A, B, B2, and sign at the X below. Administrative reviews take up to 15
days to process.
I request the plate impoundment order for the above-described vehicle be rescinded. I am the owner and possessor of the vehicle. Neither I nor any
co-owners were driving nor were passengers in the vehicle at the time of the violation. I know that the violator may not drive, operate, or be in
physical control of a vehicle without a valid driver’s license.
The above listed driver obtained the vehicle from me on (date)
The Violator/Operator of the vehicle is not a registered owner of the vehicle, and the owner of the vehicle was not a passenger, AND
1. At the time of the incident, the violator had a valid driver’s license.
2. A report was filed with law enforcement BEFORE the incident stating that the vehicle had been taken from the person’s possession
or was being used without permission. A copy of the police report must be submitted with the request for a review.
If you do not qualify to obtain new passenger plates, you may request Special Registration plates.
You may petition for Judicial Review within 30 days of the qualifying incident even if the Administrative Review is sustained.
REQUEST TO APPROVE SALE OF VEHICLE SUBJECT TO LICENSE PLATE IMPOUNDMENT
A registered owner may not sell a vehicle while the license plates are impounded or while special registration plates are displayed on the vehicle unless:
• The sale is for valid consideration (Fair Market Value)
“Gifts” are not acceptable, Low purchase prices must be accompanied by estimates from an auto repair business.
• The purchaser and registered owner or violator have no significant relationship (as defined under M.S. 169A.60) and are not related by blood, marriage, or
• The purchaser does not reside in the same residence as the registered owner or violator.
PURCHASER’S STATEMENT: Please read, check the box to the left, and sign at the “X” below:
• I request authorization to transfer the ownership of the above-described vehicle.
• I have purchased the vehicle for $
• I am not related by blood, marriage, or adoption to the registered owner or violator.
• I do not reside in the same household as the owner or violator.
• I have no significant relation as defined in M.S. 169A.60 with the registered owner or violator. (A “significant relation” is defined as any person with whom
the actor (violator/owner) regularly associates and communicates with outside of a workplace setting.)
• I know that an individual may not drive, operate, or be in physical control of a vehicle without a valid driver's license.
• I understand that a false or fraudulent statement may be a gross misdemeanor or felony.
DVS may rescind the plate impoundment order as it affects the vehicle and issue new plates at no fee if:
Signature of Vehicle Owner: X
which I attest is valid consideration.