Request for Immediate Threat
License Suspension/Revocation
Registry of Motor Vehicles ● Driver Control Unit
P.O. Box 55896 ●
Boston, MA 02205-5896
1 LE100_0318
Download and save this fillable form. Complete all highlighted fields on the form and save the file. Email the completed
file, along with any supporting documentation, to DCUImmediateThreat@massmail.state.ma.us
Documentation may also be printed and submitted to the Driver Control Unit
via FAX (857-368-0013) or mail to the address above.
A. Incident and Operator Information
Date of Request (MM/DD/YYYY) Date of Incident (MM/DD/YYYY) Incident Location City
Name of Operator License # Date of Birth (MM/DD/YYYY)
We believe that the above licensed operator has committed a violation of the motor vehicle laws of a nature that give
reason to believe that his/her continued operation will be so seriously improper as to constitute him/her an immediate
threat to the public safety (MGL c. 90 § 22).
The following incident, event, or circumstance has led us to this belief. (Include a summary of facts and attach all
copies
of documentation
to support this request. Please check box below if request is related to a medical incident.).
After reviewing the above facts, we ask you to take whatever action you deem appropriate.
Check box if request is related to a medical incident.
Signed under the penalties of perjury this _________________ day of ________________________ , _______________
Printed Name as Electronic Signature for Police Chief/Authorized Person: ______________________________________
Printed Name as Electronic Signature for Police Officer: ____________________________________________________
Police Department: __________________________________________________________________________________
Check box to confirm that you have attached all copies of documentation to support this request.
