Fillable TC94191 July2020 TC94191 July2020 (Administrative Office of the Courts)

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TC94191 July2020 TC94191 July2020 (Administrative Office of the Courts)

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KENTUCKY TRANSPORTATION CABINET
Department of Vehicle Regulation
DIVISION OF DRIVER LICENSING
TC 94-191
Rev. 06/2020
Page 1 of 1
DRIVER LICENSE/ID CARD RENEWAL
Valid only for applicants whose driver license/ID card expired or was lost or stolen
between March 1,
2020 and September 30, 2020 and who do not require additional testing
SECTION 1: APPLICANT INFORMATION
FULL LEGAL NAME (Print)
EMAIL
CELL PHONE #
I agree to receive email or text messages concerning KYTC Driver Licensing notifications.
STREET ADDRESS
CITY
ZIP
MAILING ADDRESS (if different from street address)
CITY
ZIP
DATE OF BIRTH (mm/dd/yyyy)
DRIVER LICENSE #/SSN # (last 4 digits of SSN)
EXPIRATION (mm/dd/yyyy)
SECTION 2: PAYMENT INFORMATION
Select the item you wish to purchase.
Driver License Renewal ($20.00) ID card/Duplicate License ($12.00) Combination D-M ($30.00)
Would you like to donate $1 to the Trust for Life Organ Donation Program? Yes No
Form of payment: cash check* money order debit/credit card**
*Checks should be made payable to the Office of Circuit Court Clerk.
**If paying with a debit/credit card, provide the following information:
NAME ON CARD (exactly as it appears)
CARD #
EXPIRATION (mm/yy)
SECURITY CODE (3 digits on back)
SECTION 3: APPLICANT STATUS QUESTIONS
1.
Are you a U.S. citizen? Yes No
1a. If you are not a U.S. Citizen, are you a Permanent Resident? Yes No
2.
Have you suffered a seizure or blackout within the past 90 days? Yes No
If yes, provide the date of your last seizure.
/
/
MM
DD
YYYY
3.
Is your driving privilege suspended or revoked in any state or jurisdiction? Yes No
4.
Do you have any physical/mental impairments that affect your driving abilities or have you had a blackout
within the past three (3) years? Yes No
5.
If applying for a duplicate KY license or KY ID card, was said license or ID card lost or stolen? Yes No
6.
Do you currently have a license or identification card from another state or jurisdiction? Yes No
SECTION 4: APPLICANT ATTESTATION & SIGNATURE
I affirm that I am the person named and described in the KY Drivers Licensing Information System and the statements
provided in this application and to the licensing officials are true and correct to the best of my knowledge. I understand
that misrepresentation in the licensing process can result in criminal and civil penalties under state and federal law.
APPLICANT SIGNATURE (Sign in black ink or by typing name)
DATE
Submit this application and payment by mail or drop box to the Office of Circuit Court Clerk in your county. Find contact
information here. For drop box submission, place the application with payment in a secure drop box at the entrance of the judicial
center or courthouse. It will take seven to 10 days to receive your credential by mail once your application has been processed.
Motorcycle & Operator License ($30.00)
Combination:
*Checks should be made payable to the Office of Circuit Court Clerk
Please Note: You may not use this proess to renew if you have a change in address.
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TC94191 July2020 TC94191 July2020 (Administrative Office of the Courts)

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Completed 20 July 2020

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