Fillable Mv3592 Request to Withhold Name and Address

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Mv3592 Request to Withhold Name and Address

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REQUEST TO WITHHOLD NAME AND ADDRESS
Wisconsin Department of Transportation
MV3592 9/2018 s.341.08(1m), 342.06(1)(i), 343.14(2m) Wis. Stats.
STATEMENT OF PURPOSE/EFFECT
Under Wisconsin law, Wisconsin Department of Transportation (WisDOT), Division of Motor Vehicles must provide
information from its records to requesters. If you do not want your name and address included in requests for 10 or more
records, you may ask the department to withhold your name and address from those requesters by completing and
returning this form. This form will not eliminate mailings that originate from other sources of information used by
marketers.
Certain requesters are authorized by law to receive your name and address upon request, provided such information is
used for the purpose of:
• writing and renewing insurance policies and related underwriting;
• billing and paying of insurance claims;
• vehicle safety recall notification programs; and
• law enforcement activities.
A request to withhold name and address is limited to individuals. If a vehicle is jointly owned, only the owner making
the request is affected. Once a request is processed, the designation will remain in effect until the person asks the
department to remove it.
Mail completed form to: Wisconsin Department of Transportation
P.O. Box 7983
Madison, WI 53707-7983
If you have additional questions, please write to the above address or call (608) 266-1466 for vehicle registration
information or (608) 266-2353 for driver license information.
Instructions:
To request withholding of your name and address from driver license, vehicle registration, or identification cards for the
physically disabled records, please provide the following information. Use of this form is limited to one person.
Please print legibly. Provide COMPLETE information. The following information is REQUIRED.
Name (Last, First, MI) As Shown on Driver License or Vehicle Record
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Birth Date
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Y
Residence Street Address, City, State, Zip Code
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Driver License Number (if applicable)
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Incomplete or illegible forms
will not be processed.
(Signature) (Date – m/d/yyyy)
Please check ALL that apply.
I have moved. Please record my new residence address as shown above.
I do not want my name and address provided from the Wisconsin Department of Transportation Driver or Vehicle records.
I previously requested withholding of my name and address, but want to reverse that designation.
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Mv3592 Request to Withhold Name and Address

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Completed 10 July 2020

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