Wisconsin Department of Transportation
MV3581 5/2017 s.343.265(1m) Wis. Stats.
Driver Name
Driver License Number
1 2 3 4 5 6 7 8 9 1 0 11 12 13 14
I volunteer to surrender my:
CLS – Class(es) and Endorsement(s)
EDT – Endorsement Only
Because of:
INS – Financial responsibility only, SR22
RLP – Medical reason is:
Check all classes and/or endorsements affected by the
voluntary surrender:
Classes: A B C D M
Endorsements: F H N P S T
If you wish to surrender any or all of your driving
privileges, you MUST sign and date this form. You
may need to fulll additional medical, knowledge or
skills exam requirements to regain the surrendered
classes and/or endorsements. *POA see other side
for instructions.
(Driver Signature) (Date)
During the time your driving privileges are surrendered, you are NOT permitted to drive vehicles that
require the classes and/or endorsements surrendered.
If you do not surrender all classes and/or endorsements, contact a DMV service center to complete
an application and pay a duplicate fee to obtain a license reecting the remaining classes and/or
When you are eligible for licensing of the surrendered classes and/or endorsements, a duplicate or
renewal license will be required.
If you have Power of Attorney OR guardianship of driver, you must provide a copy of the court
document for proof.
Drivers over the age of 65 who surrender driving privileges may apply for a non-expiring ID card by
going to wisconsindmv.gov/id.