CERTIFICATION OF LOST LICENSE, PERMIT OR PLATES
Use this form to explain why you can’t turn in your driver license, learner permit or license plates to DMV.
Your license and/or registration may be restored to you after you serve a suspension or revocation period. In most cases, the date you give this form to DMV will begin your compliance with the suspensionor revocation. If the effective date of theorder is laterthan the dateDMVreceivesthisform,yourcompliancewillbeginonthateffectivedate.
Instructions:
Providealltheinformationrequestedbelow.Pleaseprintyournameandmailingaddressexactly as they are printed on
your driver license, learner permit or vehicle registration.
Putacheckintheboxnexttoeachoftheitemsbelowthatyoucan’tturnintoDMV.
Inthe“Explanation”section,explainwhyyoucan’tturnintheitemsthatyoucheck.
Signinthe“Customer’sSignature”box,andreturnthisformtoanyDMVoffice.
Filingthisformwillinvalidatetheitemsthatyoucheckbelow(documentsand/orlicenseplates).Ifyoufindyoursuspended/ revokeddriverlicense,learnerpermitorlicenseplatesafteryougivethisformtoDMV,youmustimmediatelyturnintoa DMVofficeanyitemsthatyoufind.
Name __________________________________________________ |
DateofBirth: |
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MailingAddress __________________________________________________ |
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(Month/Day/Year) |
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__________________________________________________ |
ClientID# ______________________________ |
__________________________________________________ |
(orFEINif |
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acorporation) |
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Iamunabletoturninthefollowingitem(s)totheDepartmentofMotorVehicles:
oPhotoDriverLicense
oInterim/TemporaryDriverLicenseorLearnerPermit
oLearnerPermit
oLicensePlates(pleasewritetheplatenumberhere)____________________________.A police report and form MV-78B (Report of Lost, Stolen or Confiscated Motor Vehicles Items) must be provided if you have reported the plates stolen, or if both plates have been lost, and the vehicle registration is not yet expired. If one plate has been lost, the remaining plate must be turned in.
VehicleIdentificationNumber____________________________________Year_________Make_____________________
Explanation:
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
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Certification: Underthepenaltyofperjury,Icertifythat,tothebestofmyknowledge,theexplanationaboveistrue.