Withdrawal/Reinstatement of Parental Consent
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
The form can be mailed or submitted in person to Driver and Vehicle Services, 445 Minnesota St. -
Suite 170, St. Paul, Minnesota 55101-5170. It may also be faxed to 651-797-1760
• If you have questions or need additional information, please contact DVS at 651-296-2025 or
651-282-6555 (TTY).
• To ensure that this request is processed in a timely manner, please type or print legibly.
Name (LAST, FIRST, MIDDLE INITIAL)
Date of Birth (mm/dd/yy)
DL Number (OMIT DASHES)
PS33061B-01 (07/16)
A Withdrawal of Parental Consent
I am requesting that Driver and Vehicle Services cancel the driving privileges of the
above-named child, who is under age 18.
B Reinstatement
I request that the driving privileges of the above-named child, who is under age 18, be
reinstated. I understand that he or she may not operate a motor vehicle until receiving
written notification from Driver and Vehicle Services that driving privileges have been
reinstated.
I have read and fully understand the procedures for canceling and reinstating the above-named child's
driving privileges. I have informed him/her that s/he may not operate a motor vehicle until receiving written
notification from Driver and Vehicle Services that his/her driving privileges have been reinstated.
I also state that I am the parent/guardian who signed the application originally granting consent to drive, or
who signed the Withdrawal of Parental Consent/Voluntary Surrender form canceling the driving privileges
of the above-named minor child.
Parent/guardian signature of above-named minor child
Date (mm/dd/yy)
