Revised 7/2017
REQUEST FOR DRIVER’S LICENSE
OR IDENTIFICATION CARD NUMBER
The availability of records is subject to the provisions of the Uniform Motor Vehicle Records Disclosure Act.
Your signature must be notarized or the request will NOT be processed.
FORM MUST BE COMPLETED IN FULL
Name (as it appears on driver’s license or identification card):
Date of Birth: Social Security Number
Please Print Your Name:
Address:
City, State, Zip:
Telephone Number: ( )
FAX Number: ( )
Under penalty of law, the undersigned certifies that the information contained will be used as authorized by the Uniform Motor Vehicle Records
Disclosure Act. The undersigned hereby acknowledges that this request is made with the understanding that any person requesting disclosure of
personal information from the Department of Motor Vehicles who misrepresents his or her identity, misrepresents the purpose for which the
information requested will be used, or otherwise makes a false statement on the application shall be guilty of a class IV felony.
Signature: Date:
(Signature must be notarized below.)
State of
County of
The foregoing signature of the requestor was acknowledged before me this day of ,
Notary or Designated County Official
SEAL (MUST BE A STAMPED SEAL)
Submit this request to: For questions regarding this form, please contact
this office at:
FAX (402) 471-8694 (402) 471-3918
