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Get Mo Dor 4681 2020

Reset Form Form Print Form Missouri Department of Revenue Request From Driver License Record Holder Complete this form to request Driver License records including your personal information on those records. Driver License Records Record Holder s Information First Name Date of Birth MM/DD/YYYY Middle Initial Last Name Missouri Driver License or Social Security Number - Mailing Address Daytime Telephone Number City State Zip Code r Driver Record r Clearance Letter No Fee Required r Image Portfolio Black and White Photo r Temporary Driving Privilege No Fee Required r Other Specify r Yes r No r Mail provide alternate mailing address r Fax add 0. 50 per page faxed provide fax number Mailing Fax Would you like the requested records to be sent somewhere other than to the record holder s address If yes how would you like it to be sent Name Agency Name If Applicable Fax Number - Address Payment Options and Signature Records can be obtained by walk-in mail-in or e-mail request. The fee is 2. 82 per record. A convenience fee will be charged for credit or debit card transactions. The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds. You may visit us at Central Office Harry S Truman Building Room 470 301 West High Street Jefferson City Missouri. Cash Check Money Order Debit Card Discover Mail Fax Visa American Express Mastercard Total Record Fees 0. 00 - 50. 00 50. 01 - 75. 00 75. 01 - 100. 00 100. 01 or more Convenience Fee If you are paying by credit or debit card you must provide the following Name as it appears on card Card Number Expiration Date / Under penalties of perjury I declare that the above information and any attached supplement is true complete and correct. I authorize the Department of Revenue to send the requested record where I designated above. Date MM/DD/YYYY Embosser or black ink rubber stamp seal Notary Information day of year County or City of St* Louis My Commission Expires MM/DD/YYYY Notary Public Signature Notary Public Name Typed or Printed Mail to Driver License Bureau Subscribed and sworn before me this DL Record Center P. O. Box 2167 Jefferson City MO 65105-2167 Form 4681 Revised 05-2018 Phone 573 526-3669 - Option 6 then 3 Fax 573 526-7367 Visit http //www. Driver License Records Record Holder s Information First Name Date of Birth MM/DD/YYYY Middle Initial Last Name Missouri Driver License or Social Security Number - Mailing Address Daytime Telephone Number City State Zip Code r Driver Record r Clearance Letter No Fee Required r Image Portfolio Black and White Photo r Temporary Driving Privilege No Fee Required r Other Specify r Yes r No r Mail provide alternate mailing address r Fax add 0. 50 per page faxed provide fax number Mailing Fax Would you like the requested records to be sent somewhere other than to the record holder s address If yes how would you like it to be sent Name Agency Name If Applicable Fax Number - Address Payment Options and Signature Records can be obtained by walk-in mail-in or e-mail request.

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