Form DL-16LC at a glance
What it is: Acknowledgment of suspension, revocation, disqualification or cancellation as required under Section 1541 of the Vehicle Code.
Who signs: Signature in ink, and write the Date.
If you have a valid License, Permit(s) and/or Camera Card in your possession, you MUST surrender the valid product to the Department. You may not retain your PA Driver's License for photo identification purposes. This form may ONLY be used under the circumstances listed in Section B. ALL information in Section A, B, & C MUST be completed with a Signature and Date.
A filled-in Form DL-16LC example: a driver reports a lost license
How to fill out Form DL-16LC, box by box
Driver's license or permit number, name, date of birth, telephone number and e-mail address
Please type or print in blue or black ink all information.
Enter the PA DRIVER'S LICENSE/PERMIT NUMBER, first name, middle name, Jr., etc., last name, date of birth (must be listed), telephone number and e-mail address (if applicable).
Address change and voter registration
For an address change or correction only, a post office box number may be used in addition to the actual residence address, but cannot be used as the only address.
Enter the new street address, city, state and ZIP code.
This application will also serve as a request to update your voter registration unless you check this box.
If you are not registered to vote, you will receive an application to register. You must be a U.S. citizen to register to vote in Pennsylvania.
Section B: mark the appropriate box(es)
You must mark the appropriate box(es) and provide the requested information.
Box 1: Never licensed in Pennsylvania.
Box 2: the License, Permit(s) and/or Camera Card issued by Pennsylvania is Expired, Lost or Stolen.
Mark Mutilated and write when.
Mark Surrendered to or confiscated by the Police and write when and what Police Department.
Box 3: Other. You must indicate the reason that you are unable to surrender your valid License, Permit(s) and/or Camera Card if items 1 or 2 do not apply. If you have a valid PA Driver's License you may not retain it for photo identification purposes.
Section C: acknowledgment, signature and date
On the line after I, please print; you hereby acknowledge that your driving privilege is Suspended/Revoked/Disqualified in Pennsylvania.
By signing you certify that all information given on this acknowledgment is true and correct. Upon restoration, you will be required to apply for the issuance, renewal, or replacement of your Driver's License, Learner's Permit, or Camera Card, whichever is needed, in order to be licensed in Pennsylvania. If using a messenger service, you authorize the Department to furnish them with your driving record for the purpose of processing this form.
Signature in ink, and write the Date.
More rules for Form DL-16LC
Upon receipt, review and acceptance of this acknowledgment, PennDOT will send you a receipt. If you do not receive this receipt within 3 weeks of your mailing, call 717-412-5300. TTY callers should dial 711.
Common questions about Form DL-16LC
Where do I file it?
Unless this document is being submitted by a Court of Record following sentencing, mail this form to PennDOT, Bureau of Driver Licensing, P.O. Box 68693, Harrisburg, PA 17106-8693.
Is there a penalty?
Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500.00 (checked November 1, 2026) and/or imprisonment up to one year (18 PA C.S. Section 4904(b)).
Sources
[1] Form DL-16LC (12-21), Acknowledgment of Suspension/Revocation/Disqualification/Cancellation as Required Under Section 1541 of the Vehicle Code, Pennsylvania Department of Transportation (the Official source link on this page).
