Fillable dmv.ciu@ct.gov (SEE INSTRUCTIONS ON BACK) STATE OF CONNECTICUT (State of Connecticut/Department of Administrative Services)

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dmv.ciu@ct.gov (SEE INSTRUCTIONS ON BACK) STATE OF CONNECTICUT (State of Connecticut/Department of Administrative Services)

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CONNECTICUT RESIDENT ADDRESS (Number, Street, City or Town, State, Zip Code) MILITARY: Connecticut address at time of induction
CONNECTICUT MAILING ADDRESS (If different from Connecticut resident address)
THIS FORM CANNOT BE USED TO CHANGE YOUR ADDRESS PERMANENTLY. YOU
MUST COMPLETE AN INDIVIDUAL CHANGE OF ADDRESS FORM (B-58) TO CHANGE
YOUR ADDRESS.
The information provided to the Commissioner of Motor Vehicles on this form is subscribed by me, the undersigned, under penalty of false statement, in accordance with the
provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes. I understand that if I make a statement that I do not believe to be true, with the intent to mislead
the Commissioner, I will be subject to prosecution under the above referenced laws. Additional Certification for Driver's Licenses; I also swear or affirm, under penalty of
false statement, that my driver's license or driving privilege is not suspended, revoked or withdrawn, and that I do not have any health problems or conditions that prevent me
from driving safely.
E-MAIL ADDRESS
PHONE NUMBER YOU CAN BE REACHED AT
(If available)
APPLICANT'S SIGNATURE
X
DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR REGISTRY?
IF YES, YOU ARE AGREEING TO BE A DONOR AND THE
DESIGNATION WILL BE ON YOUR LICENSE.
YES
NO
REQUEST FOR A CONNECTICUT DRIVER'S
LICENSE/IDENTIFICATION CARD BY MAIL
B-350 Rev. 12-2020
(SEE INSTRUCTIONS ON BACK)
NAME OF APPLICANT ON DRIVER'S LICENSE (Last, First, Middle Initial)
DRIVER'S LICENSE OR ID CARD NUMBER (If known)
DATE OF BIRTH
STREET ADDRESS WHERE LICENSE IS TO BE MAILED
EYE COLOR
GENDER
HEIGHT
CITY
STATE
COUNTRY
ZIP/POSTAL CODE
CLASS (If known)
ENDORSEMENTS (If known)
RESTRICTIONS (If known)
SECTION B - CERTIFICATION FOR DRIVER'S LICENSE AND IDENTIFICATION CARDS
CREDIT CARD PAYMENT Please provide an
email address above and you will be sent a link
for payment within 2 business days. If you do not
receive a link call (860) 263-5401
SECTION A
Total Enclosed $
Payment Enclosed (check or money order)
DO NOT COMPLETE BELOW THIS LINE UNLESS YOU WANT TO REGISTER TO
VOTE OR CHANGE YOUR POLITICAL PARTY AFFILIATION.
NOAre you a citizen of the United States of America? YES
Will you be at least 18 years of age on or before election day? YES NO
If you checked "NO" in response to either of these questions, do NOT complete
below this line as you cannot register to vote.
Do you wish to enroll in a political party?
YES NAME OF PARTY: DEMOCRATIC REPUBLICAN
OTHER
NO I DO NOT WISH TO ENROLL IN A PARTY AT THIS TIME AND WILL BE
REGISTERED AS UNAFFILIATED,
Note: Declaring a party enables you to vote in the party's primary election, which is open
only to party members. You may later choose to switch enrollment to or from a political
party.
LEAVING THIS BOX BLANK WILL AUTOMATICALLY RESULT IN SELECTING "UNAFFILIATED".
VOTER DECLARATION - I swear or affirm under penalty of perjury that:
* I am a U.S. Citizen;
* I live in Connecticut at the address shown above;
* I am at least 17 years old and will be at least 18 years old on or before
election day;
* I have not been convicted of a disenfranchising felony, or if so, I am
eligible to register to vote.
The information that I have provided is true to the best of my knowledge under
penalty of perjury. If I have provided false information, I may be subject to a fine or
imprisonment or both under federal or state laws.
By signing this Voter Declaration, I am applying to register to vote or changing my existing
party affiliation, and I agree to allow the signature from my license record to be used as
the signature on my voter registration record.
X SIGNATURE FOR VOTER REGISTRATION ONLY**
TODAY'S DATE
** Voter registrations without signatures will not be processed.
FEE STRUCTURE FOR CREDENTIALS EXPIRING IN 2020 & 2021.
The day of your date of birth determines your renewal period.
Day of Date of Birth Renewal Period
1,3,4,6,7,8,10,12,13,15,16,18,19,21,23,24,25,27,30 6 year renewal
2,5,9,11,14,17,20,22,26,28,29,31
8 year renewal
For example, if you were born on October 27, you will receive a 6-year
renewal period and pay $72.00.
SECTION C - FEES
SECTION D - VOTER REGISTRATION APPLICATION
Check the applicable fees and determine correct amount
TRANSACTION TYPE FEES
Duplicate License/Non Driver ID $ 30.00
Duplicate Commercial Permit $ 10.00
Duplicate Learners Permit $ 19.00
Renewal of Drivers License 6 years (See above) $ 72.00
Renewal of Drivers License 8 years (See above) $ 96.00
Renewal of Drivers License 2 years* (65 & Older) $ 24.00
Renewal of Non Drivers ID 6 years $ 24.00
Renewal of Non Drivers ID 8 years $ 32.00
LATE FEE- For renewal of driver license if received by DMV
$ 25.00
after expiration date.
DATE
NO CASH
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
CENTRALIZED ISSUANCE UNIT
60 STATE ST, WETHERSFIELD,CT 06109
dmv.ciu@ct.gov
INSTRUCTIONS:
1.
2.
3.
4.
5
6.
NOTE:
ACTIVE MILITARY PERSONNEL ONLY SECTION E
I AM ENTITLED TO A WAIVER
BECAUSE OF (Check One)
Present Active Service in U.S. Armed Forces
Honorably Separated From Active Service
(If checked, fill in date of separation and submit copy of separation papers -DD214)
DATE OF INDUCTION
DATE OF SEPARATION
NAME AND MAILING ADDRESS OF ARMED FORCES UNIT
I certify that I was a legal resident of the state of Connecticut at the time of my induction and that all
information provided in this application is correct.
X
SIGNATURE OF APPLICANT
I certify under penalty of false statement in accordance with provision of Section 14-110 and 53a-157b
of the Connecticut General Statutes that the above named applicant is in the active service of the U.S.
Armed Forces. I understand that if I make a statement which I do not believe to be true, with the
intent to mislead the Commissioner, I will be subject to prosecution under the above referenced laws.
SIGNATURE OF COMMISSIONED OFFICER IN CHARGE (If Active)
X
RANK
BRANCH OF SERVICE
Connecticut General Statutes, Section 14-50(c). The Commissioner of Motor Vehicles shall waive the operator's license fee and examination fee in the case
of any person in the active service of the armed forces of the United States who was a legal resident of Connecticut at the time of his induction; and for one
licensing period to any person honorably separated from service who applies therefore within two years following the date of separation and was a legal
resident of Connecticut at the time of his induction.
Complete Section A entirely. Type or print clearly. Sign the certification in section B.
Complete Section D if you want to apply to register to vote in CT or change your party affiliation. To register, you
must be a U.S. citizen and at least 18 years old on or before the next election. You are not a voter until your
application is approved by the registrar of voters in your CT town of residence. If you do not receive an acceptance
or rejection within three weeks, contact your town registrar of voters.
Military: If recently honorably discharged or an active member of the armed services of the United States, Section E
(below) must be completed if requesting a no fee renewal. A fee exemption is not given for duplicate licenses or
identification cards.
Send completed application through either postal mail or e-mail (e-mail will reduce wait time).
LICENSE RENEWALS: Payments must be received prior to or the day of expiration or a $25.00 late fee will be
charged.
The following transactions cannot process through the mail. Renewal of commercial driver license (CDL), public
service license, name change, or drive-only permit / license.
MAIL
Send the completed application and payment (fees are listed in section C) of check or money order drawn on a
United States bank (dollar currency) and mailed to:
Department of Motor Vehicles
60 State Street
Wethersfield, CT 06109
Attn: Central Issuance Operations Unit
dmv.ciu@ct.gov
E-MAIL
E-mail completed form(s) to dmv.ciu@ct.gov. Within 2 business days you will receive a link to make a credit card
payment (MASTERCARD, VISA, DISCOVER OR AMERICAN EXPRESS ONLY). If you do not receive a link within
2 business days call 860-263-5401.
Per the REAL ID act you are allowed only one renewal through the mail before a new photo is required.
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dmv.ciu@ct.gov (SEE INSTRUCTIONS ON BACK) STATE OF CONNECTICUT (State of ConnecticutDepartment of Administrative Services)

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Completed 27 January 2021

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