Driving Record Abstract Request Form DC164 Dsd

Printed by authority of the State of Illinois. January 2017 - 1 - DSD DC 164.11

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 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.

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:

Name First M.I. Last

________________________________________________________________________________________________________________________________

Residential Address

________________________________________________________________________________________________________________________________

City State ZIP Code

Name of Person or Organization I am representing

________________________________________________________________________________________________________________________________

Address of Person or Organization

________________________________________________________________________________________________________________________________

City State ZIP Code

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.): ____________________

Detective State Registration #: _____________________

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 #: ______________________________________

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

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”)

need for the abstract(s) requested. Complete Section III. (PUB-FEE-”D”)