Request for Fraudulent License/ID Card
Suspension/Revocation
Registry of Motor Vehicles ● Enforcement Services Unit
P.O. Box 55889 ● Boston, MA 02205-5889
1 LE102_0318
Download and save this fillable form. Complete all highlighted fields on the form, save, and print the file.
FAX this form and all supporting documentation to the RMV’s Enforcement Services Unit at 857-368-0649.
Call 857-368-9500 if you have any questions.
Date of Request (MM/DD/YYYY)
Date of Incident (MM/DD/YYYY)
Name (As it appears on Mass credential presented) License/ID # Date of Birth (MM/DD/YYYY)
As a result of the above dated incident/investigation, the following action has been taken against this individual:
Individual arrested for violating MGL c. 90 § 24 B.
Individual issued a citation for MGL c. 90 § 24 B. If checked, provide Citation #: __________________________________________
Department is seeking/has filed a criminal complaint against individual for MGL c. 90 § 24 B.
License/ID Holder’s True Identity is:
Known
Unknown Explain:
Under MGL c. 90, § 22 (e), the RMV may apply an administrative license suspension/revocation, known as a Complaint Fraudulent
License (CFL). Individuals facing a CFL are provided 10 days to comply with an RMV hearing request or face indefinite suspension until
the individual appears and satisfies all RMV identity requirements.
Use the box below to clearly identify all License Number(s), Social Security Number (s), Date of Birth (s), and aliases that you believe are
associated with this individual and which should be suspended/revoked; include what has led you to question the individual’s identity.
Submit photocopies of all credentials, all supporting documents, and police reports. After reviewing all the facts provided, the RMV will take
whatever action the agency deems appropriate. NOTE: If this individual was involved in an incident that presents any immediate threat to
public safety under MGL c. 90 § 22, please complete the Request for Immediate Threat License Suspension/Revocation
form.
Printed Name as Electronic Signature for Police Chief/Authorized Person: ________________________________________________
Printed Name as Electronic Signature for Police Officer: ______________________________________________________________
Police Officer’s Contact Info, Email, or Phone: ______________________________ Police Department: ________________________
Check box to confirm that you have attached all copies of documentation/reports to support this request.
Check box if you wish to be notified if this individual makes an appointment for a hearing.
