California Id Card Form – Fill Out and Use This PDF

INSTRUCTIONS (Please use Blue or Black ink.)

If your last TWO identification card renewals or your LAST Senior identification card renewal was by mail or by Internet, you are NOT eligible to renew by mail or online. You MUST provide your Social Security Number when applying.

If you answered YES to questions B and C, you are not eligible for renewal by mail. Make an appointment to visit your local DMV office to renew in person.

If you answered YES to questions A and D, you are eligible for renewal by mail. Complete the attached form.

DISCLOSURES

VETERAN STATEMENT

By marking the veteran box on this application, I certify that I am a veteran of the United States Armed Forces and that I want to receive veteran benefits information from the California Department of Veterans Affairs (CalVet). By marking the veteran box on this application, I also consent to DMV transmitting my name and mailing address to CalVet for this purpose only, and I certify that I have been notified that this transmittal will occur.

ORGAN DONOR STATEMENT

If you marked ‘Yes’ to register as an organ and tissue donor, you are legally authorizing the recovery of organs and tissues in the event of your death. Registering as a donor will not affect your medical treatment in any way. As outlined in the California Anatomical Gift Act, your authorization is legally binding and, unless the donor is under 18 years of age, your decision does not require the consent of any other person. For registered donors under 18 years of age, the legal guardian shall make the final donation decision. You may limit your donation to specific organs or tissues, place usage restrictions (for example transplantation or research), obtain more information about donation, or remove your name from the registry on the website of Donate Life California: www.donateLIFEcalifornia.org. By registering as an Organ Donor, you are giving your consent to allow DMV to electronically transmit your true full name, residence or mailing address, year of birth, and California driver license or identification card number to Donate Life California. By signing this form, you consent to this process and have been notified that this transmittal will occur.

VOTER REGISTRATION

•If sharing your address could put you in life-threatening danger, you may be eligible to register to vote confidentially. For more information, contact the Safe at Home program at (877) 322-5227 or visit www.sos.ca.gov/safeathome/.

•For U.S. citizens only. If you indicate that you are eligible to vote, the DMV will send all of the voter registration information collected on this form, including your digital signature, to the Secretary of State. The office where you registered will remain confidential and will be used only for voter registration purposes.

•If you are eligible to vote and decline to register to vote, your decision will remain confidential; however this information will be sent to the Secretary of State to be used only for voter outreach and registration purposes.

•Voter registration information provided on this application is confidential. The DMV does not make voter eligibility determinations.

•If you have not received voter registration information within four weeks of registering, contact your county elections official or the Secretary of State.

•Please visit voterstatus.sos.ca.gov/ for more information about your voter registration or www.sos.ca.gov for general information.

CRIMINAL PROSECUTION

•If you submit fraudulent information, the DMV may pursue criminal prosecution.

•Any person who uses false documents to conceal their true citizenship or resident alien status is guilty of a felony pursuant to California Penal Code §114.

FINANCIAL RESPONSIBILITY

•Financial responsibility (commonly known as insurance) is required on all vehicles operated or parked on California roadways. You must carry evidence of financial responsibility in your vehicle at all times and it must be provided when: requested by law enforcement, renewing vehicle registration, the vehicle is involved in a traffic collision.

•If you cannot afford liability insurance, you may be eligible for the California Low Cost Automobile Insurance Program. Additional information is available at www.mylowcostauto.com or by calling (866) 602-8861.

PAYMENTS / REFUNDS

•Visit www.dmv.ca.gov to review payment options at your local DMV field office. If you are mailing your renewal, payment must be by check. (Checks should be payable to DMV).

•Once this application form and fee have been submitted, no refunds will be made.

PRIVACY NOTICE

•DMV uses the information on this form to determine your eligibility for a Driver License or Identification Card and for the administration of driver license laws.

•Information provided to DMV on this form is collected and subject to the limitations in the Information Practices Act (Civil Code 1798 et seq.), the Driver’s Privacy Protection Act (18 U.S.C. 2721-2725), the California Vehicle Code (CVC) and other applicable state and federal laws and regulations.

•DMV verifies the information and documents you provide with other governmental agencies.

•All information on this form is mandatory except where noted. DMV may deny your application for not providing the required information. Failure to provide the information required on this form is cause for refusal to issue a driver license or identification card, or, in some cases, cancellation or withdrawal of the driving privilege.

•DMV shares your information with other governmental agencies, law enforcement, and commercial entities as authorized by law. You may obtain a copy of your record at www.dmv.ca.gov or at any DMV field office during regular office hours. For assistance with access to your record, call (800) 777-0133 or make an appointment to visit a DMV field office during regular busi- ness hours. For assistance with corrections to your record, contact DMV’s Licensing Operations Division Mandatory Actions Unit at (916) 657-6525.

•QuestionsregardingyourDriverLicenseorIdentificationCardshouldbeaddressedto:DriverLicenseInquiries,DepartmentofMotorVehicles,POBox942890,Sacramento,CA94290-0001.

•For more information regarding specific CVC Sections or how DMV shares your information, please visit www.dmv.ca.gov. You may also request a copy of How Your DMV Information is Shared (FFDMV 17) Fast Facts brochure from any field office.

•DMV’s Privacy Policy is located at www.dmv.ca.gov under the “Privacy Policy” link at the bottom of the page.

•Questions regarding this notice should be addressed to: Department of Motor Vehicles, ATTN: Chief Privacy Officer – MS F127, PO Box 932328, Sacramento, CA 94232-3280.

CERTIFICATIONS

•I agree to submit to a chemical test of my blood, breath, or urine for the purpose of determining the alcohol or drug content of my blood when testing is requested by a peace officer acting in accordance with California Vehicle Code (CVC) §23612.

•I am hereby advised that being under the influence of alcohol or drugs, or both, impairs the ability to safely operate a motor vehicle. Therefore, it is extremely dangerous to human life to drive while under the influence of alcohol or drugs, or both. If I drive while under the influence of alcohol or drugs, or both, and as a result, a person is killed, I can be charged with murder.

•By signing this application, I certify that I was notified that if I am under 21 years of age, I cannot legally drive with a blood alcohol concentration (BAC) of 0.01% or more. Driving with a BAC of 0.01% or more, or refusing to take, or failing to complete an alcohol screening or drug test, results in a one-year suspension of my driving privilege.

•By signing this application, I certify that I was notified that if I am currently on court probation for a driving under the influence offense, I cannot legally drive with a BAC of 0.01% or more. Driving with a BAC of 0.01% or more results in a one-year suspension of my driving privilege. Refusing to take, or failing to complete an alcohol screening or chemical test will result in a two to three year suspension/revocation of my driving privilege.

•I am the person whose name appears on the front of this form. The mailing address shown is valid, existing, and accurate. I agree to accept service of process at this mailing address according to §§415.20(b), 415.30(a), and 416.90 of the California Code of Civil Procedure.

•I understand DMV may add traffic convictions reported by other states or jurisdictions to my driving record that may result in sanctions against my California driving privilege.

•By signing this form, I am acknowledging my presence in the United States is authorized under federal law, except as specified in CVC §12801.

•I understand I may have no more than one driver license in my possession or under my control in accordance with CVC §12511.

•By signing this application, I certify that I understand traffic signs and signals in accordance with CVC §12800(h).

704

CALIFORNIA IDENTIFICATION CARD OR SENIOR IDENTIFICATION CARD

SECTION 1 — PLEASE TELL US ABOUT YOURSELF (Use your true full name.) (Please use Blue or Black ink.)

Do you wish to be an organ or tissue donor?

Yes, add or keep my name on the donor registry.

Marking “Yes” adds your name to the Donate Life California Organ and Tissue Donor Registry and a pink ‘donor’ dot will appear on your DL/ID card. You must mark “Yes” to maintain the donor dot on your DL/ID card.

I do not wish to register to be an organ or tissue donor at this time.

Marking “I do not wish to register at this time” will not remove you from the registry. If you wish to remove your name from the registry, you must contact Donate Life California (see page 1). DMV can remove the pink dot from your DL/ID card but cannot remove you from the registry.

Would you like to make a voluntary contribution?

Mark this box to provide a $2 voluntary contribution to support and promote organ and tissue donation.

(Page 2 of 3) IMPORTANT: CONTINUE TO NEXT PAGE.

WE CANNOT PROCESS YOUR RENEWAL WITHOUT PAGES 2 & 3.

SECTION 5 — VOTER REGISTRATION— FOR U.S. CITIZENS ONLY.

It is a crime to intentionally provide incorrect information on a voter registration form.

(State law requires eligible citizens be automatically registered to vote, unless they choose not to in this section.)

If you answered “YES” to all of the voter registration requirements listed below, you can register to vote:

•I am a United States citizen

•My residence address is in California

•I am at least 18 years old (You may pre-register if you are 16 or 17, but you must be 18 or older to vote on Election Day.)

•I am not currently serving a state or federal prison term for the conviction of a felony

•I am not currently found mentally incompetent to vote by a court

•If you answered “No,” you cannot register to vote. Skip to Section 7.

•If you answered “Yes” to the above questions, you will be registered to vote. You can choose not to register by checking the box below.

5c. I am eligible, but I do not want to register to vote or update my voter registration information. Skip to Section 7.

•Do not check this box if you want to register to vote or update your voter registration information. Continue to Section 6.

SECTION 6 — VOTER PREFERENCES— FOR U.S. CITIZENS ONLY.

(To choose or update any voter preferences, you must first indicate you are eligible to vote in Section 5 above.)

If you answer “Yes,” you will receive a vote-by-mail ballot for all elections. You can always vote in person by turning in your vote-by-mail ballot, or voting a provisional ballot, at your polling place.

In what language would you like to receive election materials? (Select only one.)

Contact Information for voter registration. (Optional)

Telephone Number: (EXAMPLE: 916-555-1212)

I want to remove my telephone number.

Email address: (EXAMPLE: john.doe@company.com)

I want to remove my email address.

If you do not receive a voter notification card within four weeks, contact your county elections official.

You can also check your voter registration status at https://voterstatus.sos.ca.gov/.

SECTION 7 — SIGNATURE/PERJURY STATEMENT

I have read, understand and agree with the certifications on this document. I certify (or declare) under penalty of perjury under the laws of the State of California that the information I provided is true and correct.

SECTION 8 — WHERE TO MAIL

The renewal fee for an identification card is $33.00. If you marked the box to make a $2 voluntary contribution to support and promote the Donate Life California organ and tissue donor registry, include the $2 voluntary contribution with your check or money order made payable to DMV and mail this form to:

DMV

DL 410 – MS G204

PO Box 942890

Sacramento, CA 94290-0001

(Please write your identification card number on the back of your payment document.)