Driving Record Abstract Request Form DC164 Dsd
User Manual: DC164
Open the PDF directly: View PDF 
.
Page Count: 2
| Download | |
| Open PDF In Browser | View PDF |
Print Office of the Secretary of State Reset Save 2701 S. DIRKSEN PKWY. SPRINGFIELD, IL 62723 217-782-2720 www.cyberdriveillinois.com Driver Services Department Driving Record Abstract Request Form All requestors must complete Sections I, II, IV and V. SECTION I Enter the Driver’s License Number and/or the Name and Date of Birth of the driver(s) whose record(s) is being requested in the spaces below. PLEASE PRINT LEGIBLY. DRIVER’S LICENSE NUMBER ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ NAME (Last, First, Middle) ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ DATE OF BIRTH ____________________ ____________________ ____________________ ____________________ ____________________ GENDER ____________ ____________ ____________ ____________ ____________ SECTION II – REQUESTOR’S IDENTITY Driver’s License, Permit or ID Number:_____________________________________________________________________________ For yourself: ☐ Yes ☐ No If no, complete Section III. Name First M.I. Last ________________________________________________________________________________________________________________________________ Residential Address ________________________________________________________________________________________________________________________________ City State ZIP Code SECTION III – If you classified yourself as a representative or agent of anyone other than yourself in Section II, you must provide the following information. Complete Section IV on reverse. Name of Person or Organization I am representing ________________________________________________________________________________________________________________________________ Address of Person or Organization ________________________________________________________________________________________________________________________________ City State ZIP Code If the record(s) you requested must be mailed, to which address above should it be mailed: ☐ Section II ☐ Section III SECTION IV (Please see reverse.) SECTION V – AFFIRMATION OF REQUESTOR I affirm that the information in Sections I, II, III and IV are true and correct to the best of my knowledge. I understand that if any of the information provided by me in these sections is knowingly false or misleading, administrative, civil and/or criminal actions may be taken against me. (Notarization required if mailing form.) Notary Seal Signature: ____________________________________ Date: ____________________ SECRETARY OF STATE USE ONLY Identification Checked:______________________________________________________________________________________________________ Employee Signature: ______________________________________________________ Date: ________ - ________ - ________ Number of Certified Records: ________ x $12.00 = ________ Type of Record: __________________________________________ Number of Photocopies: ____________ x $ 1.00 = ________ Cash Number of Certifications: ____________ x $ 2.00 = ________ MO Check Credit Card Printed by authority of the State of Illinois. January 2017 - 1 - DSD DC 164.11 SECTION IV Place an “X” in front of the category below that describes you concerning the record(s). Mark only one category per request form. Items within ( ) are for Secretary of State personnel. Purpose of Request (This information must be provided if you mark a box that has an asterisk next to it.): ____________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ I AM: * ■ the person named on the abstract requested. (AFF or PUB-FEE “S”) * ■ a law enforcement or court official with an official need for the abstract(s) requested. Complete Section III. (CRT or EXT-NO FEE “L”) * ■ a private investigative agency or security service licensed in Illinois for any purpose permitted under 625 ILCS 5/2-123 of the Illinois Vehicle Code. Complete Section III. (PUB-FEE-”H”) Detective State Registration #: _____________________ * ■ the legal representative of the person(s) named on the abstract(s) requested. Complete Section III. (AFF or PUB-FEE-”R”) Attorney State Registration #: __________________________________________ ■ an attorney not representing the person(s) named on the abstract(s) requested but needing the abstract(s) for legal business involving the affected driver(s). Complete Section III. (PUB-FEE-”A”) Attorney State Registration #: ______________________________________ * ■ the parent/legal guardian of the minor person(s) (under age 18) named on the abstract(s) requested. I am submitting the minor’s signed and notarized consent to obtain his/her abstract. (AFF or PUB-FEE-”P”) ■ an immediate family member (parent/legal guardian, brother, sister, spouse, grandparent, child or grandchild) of the adult (age 18 or older) named on the abstract(s) requested. I am submitting the adult’s signed and notarized consent to obtain his/her abstract. (PUB-FEE-”F”) Relationship: _________________________________________ ■ a representative of a local, state or federal government agency, with an official business need for the abstract(s) requested to carry out the agency function on this request form. Complete Section III. (EXT-NO FEE-”G”) If an elected official, office held: _________________________________________________ ■ a representative of the insurance industry with a legitimate insurance business need for the abstract(s) requested. Complete Section III. (PUB-FEE-”I”) ■ the employer, prospective employer, or representative of the employer or prospective employer of the person(s) named on the abstract(s) requested. I am submitting the employee’s signed and dated consent form. If I am coming into a facility, I will bring in the employees signed and dated consent form. The abstract(s) is needed for business purposes pertaining to the person’s(s’) employment or prospective employment. Complete Section III. (PUB-FEE-”E”) ■ a representative of a financial institution with a legitimate business need for the abstract(s) requested. Complete Section III. (PUB-FEE-”B”) ■ a representative of a new or used vehicle dealership, vehicle rental agency, or tow truck operation with a legitimate business need for the abstract(s) requested. Complete Section III. (PUB-FEE-”D”) ■ none of the above. The abstract(s) requested will be mailed to you by the Secretary of State Driver Services Department in Springfield in approximately 10 business days. The Secretary of State’s office will send a letter to each person for whom a driving abstract is requested approximately 10 days prior to mailing his/her abstract(s) to you. The letter will inform the person(s) of the date of your purchase and your name. NOTE: The abstract(s) requested will not list the address or personal information of the individual(s). (PUB-Fee ”N”)
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.6 Linearized : Yes Create Date : 2017:02:01 14:23:20-06:00 Modify Date : 2017:02:02 07:27:13-06:00 X Press Private : %%DocumentProcessColors: Cyan Magenta Yellow Black.%%EndComments Has XFA : No XMP Toolkit : Adobe XMP Core 5.4-c005 78.147326, 2012/08/23-13:03:03 Creator Tool : QuarkXPress(R) 11.01 Metadata Date : 2017:02:02 07:27:13-06:00 Producer : QuarkXPress(R) 11.01 Format : application/pdf Title : Driving Record Abstract Request Form Creator : State : 1 Version : 1.1 Document ID : uuid:166fe174-acd9-cd44-bdc0-93ed2ea6a631 Instance ID : uuid:f71cd0e0-b146-ec4c-92eb-1aa603fc06d2 Page Count : 2 Signing Date : 2017:02:02 07:27:13-06:00 Signing Authority : ARE Acrobat Product v8.0 P23 0002337 Annotation Usage Rights : Create, Delete, Modify, Copy, Import, Export Document Usage Rights : FullSave Form Usage Rights : Add, FillIn, Delete, SubmitStandalone Signature Usage Rights : ModifyEXIF Metadata provided by EXIF.tools