Fillable RECORD CHANGE REQUEST (Town of Hampton, NH)

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RECORD CHANGE REQUEST (Town of Hampton, NH)

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  • 5 check-boxes
  • 26 other fields

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File type: PDF

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Robert L. Quinn
Commissioner of Safety
STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES
23 HAZEN DRIVE, CONCORD, NH 03305-0001
Telephone: (603) 227-4000 Relay NH (7-1-1)
www.nh.gov/dmv
Elizabeth A. Bielecki
Director of Motor Vehicles
RECORD CHANGE REQUEST
Note: This request will change data on all DMV records (Registration, Driver License, Title, etc.)
Please complete form accordingly for permanent changes only.
1. Person’s Information: (Please Print)
NAME:
FIRST MIDDLE LAST
DATE OF BIRTH
Driver License or Non Driver ID Number
Best Contact Phone Number (Recommended)
2. Address Change:
If you would like a replacement license/ID with the updated information go to any
DMV Office and you may purchase a replacement at a cost of $3.00.
MAILING ADDRESS:
STREET
CITY/TOWN
STATE
ZIP CODE
Check this box if the legal address is the same as the mailing, if different please complete legal address below.
LEGAL ADDRESS:
STREET
CITY/TOWN
STATE
ZIP CODE
Check this box if you wish to have your legal address appear on the back of your driver license or ID.
Check if you wish to add the Veteran Indicator. ** Must provide proof of honorable discharge**
3. Name Change: Must appear in person at any DMV Office with supporting documentation.
Marriage Certificate, Divorce decree, Adoption decree, Court decree, Name Change Petition from Probate Court, Passport.
NEW NAME:
FIRST
MIDDLE
LAST
SUFFIX (Jr. Sr. I, II, etc)
4. Other Personal Identification Information:
To change Date of Birth you must appear in person
at any DMV Office with supporting documentation. Original or certified copy of Birth Certificate, valid
Passport or valid Military ID.
Height
Weight
Eye Color
Hair Color
Gender
Date of Birth (mm/dd/year)
5. Donor Information:
Check Here To Consent to Organ Donation pursuant to RSA 263:41.
Donation information will be provided to federally designated organizations so that your decision to donate may be honored.
Check here
to remove your consent to Organ and Tissue donation.
I, the undersigned applicant, certify under penalty of unsworn falsification pursuant to RSA 641:3, all information
provided is correct and true.
Signature:_________________________________________ Date:_______________________________
FOR OFFICE USE ONLY: Cash Check Credit Card
DSMV 30 (Rev 5/19)
John J. Barthelmes
Commissioner of Safety
STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES
23 HAZEN DRIVE, CONCORD, NH 03305-0001
Telephone: (603) 227-4000 Relay NH (7-1-1)
www.nh.gov/dmv
Elizabeth A. Bielecki
Director of Motor Vehicles
RECORD CHANGE REQUEST
Note: This request will change data on all DMV records (Registration, Driver License, Title, etc.)
Please complete form accordingly for permanent changes only.
1. Person’s Information: (Please Print)
NAME:
FIRST MIDDLE LAST
DATE OF BIRTH
Driver License or Non Driver ID Number
Best Contact Phone Number (Recommended)
Email Address
2. Address Change:
If you would like a replacement license/ID with the updated information go to any
DMV Office and you may purchase a replacement at a cost of $3.00.
MAILING ADDRESS:
STREET
CITY/TOWN
STATE
ZIP CODE
Check this box if the legal address is the same as the mailing, if different please complete legal address below.
LEGAL ADDRESS:
STREET
CITY/TOWN
STATE
ZIP CODE
Check this box if you wish to have your legal address appear on the back of your driver license or ID.
Check if you wish to add the Veteran Indicator. ** Must provide proof of honorable discharge**
3. Name Change: Must appear in person at any DMV Office with supporting documentation.
Marriage Certificate, Divorce decree, Adoption decree, Court decree, Name Change Petition from Probate Court, Passport.
NEW NAME:
FIRST
MIDDLE
LAST
SUFFIX (Jr. Sr. I, II, etc)
4. Other Personal Identification Information:
To change Date of Birth you must appear in person
at any DMV Office with supporting documentation. Original or certified copy of Birth Certificate, valid
Passport or valid Military ID.
Height
Weight
Eye Color
Hair Color
Gender
Date of Birth (mm/dd/year)
5. Donor Information:
Check Here To Consent to Organ Donation pursuant to RSA 263:41.
Donation information will be provided to federally designated organizations so that your decision to donate may be honored.
Check here
to remove your consent to Organ and Tissue donation.
I, the undersigned applicant, certify under penalty of unsworn falsification pursuant to RSA 641:3, all information
provided is correct and true.
Signature:_________________________________________ Date:_______________________________
FOR OFFICE USE ONLY: Cash Check Credit Card DSMV 30 (Rev 10/17)
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RECORD CHANGE REQUEST (Town of Hampton, NH)

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Completed 3 August 2020

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