Dl 16Lc Form PDF Details

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Form NameDl 16Lc Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesacknowledgment suspension, how to obtain a dl16lc form, pennsylvania form revocation, pa dl16lc

Form Preview Example


DL-16LC (7-10)

Acknowledgment oF SUSPenSIon/ ReVocAtIon/dISQUAlIFIcAtIon/cAncellAtIon

AS ReQUIRed UndeR SectIon 1541 oF tHe VeHIcle code

PleASe tYPe oR PRInt In BlUe oR BlAck Ink All InFoRmAtIon

Bureau of Driver Licensing

P.O. Box 68693 • Harrisburg, PA 17106-8693

If you have a valid license, Permit(s) and/or camera card in your possession, you mUSt surrender the valid product to earn suspension credit. You may not retain your PA driver's license for photo identiication 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 or credit will not be given.





pA dRiVeR'S liceNSe/peRmit NumBeR

lASt NAme


fiRSt NAme

middle NAme

















dAte of BiRtH (must be listed)

telepHoNe NumBeR

e-mAil AddReSS (if applicable)






















AddReSS cHANGe: A poSt office Box NumBeR mAy Be uSed iN AdditioN to tHe ActuAl ReSideNce AddReSS, But cANNot Be uSed AS tHe oNly AddReSS.






zip code




if you are a registered voter in pA, would you like us to notify your county voter registration office of this change?

yeS No

if you are not a registered voter, you may contact your county voter registration office.


You mUSt mark the appropriate box(es) and provide the requested information.

1.Never licensed in Pennsylvania.

2.License, Permit(s) and/or Camera Card issued by Pennsylvania is:




Mutilated: When?_______________________________________________________________________________________

Surrendered to or confiscated by the Police. When: ______________________________________

What Police Department? ________________________________________________________________________________

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): _______________________________________________________________________________________________



I, ____________________________________ hereby acknowledge that my driving privilege is Suspended/Revoked/Disqualified in Pennsylvania.


I certify that all information given on this acknowledgment is true and correct and hereby apply for proper credit. I understand that upon restoration, I will be required to apply for the issuance, renewal, or replacement of my Driver's License, Learner's Permit, or Camera Card, whichever is needed, in order to be licensed in Pennsylvania. If using a messenger service, I hereby authorize the Department to furnish them with my driving record for the purpose of processing this form.





wARnIng: Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500.00 and/or imprisonment up to one year (18 PA C.S. Section 4904(b)).

AddItIonAl InFoRmAtIon

Unless this document is being submitted by a Court of Record following sentencing, this form must be mailed to:

Penndot • Bureau of driver licensing • P.o. Box 68693 • Harrisburg, PA 17106-8693

Upon receipt, review and acceptance of this acknowledgment, PennDOT will send you a receipt confirming the date that credit began. If you do not receive this receipt within 3 weeks of your mailing, please contact PennDOT at the telephone numbers listed below to verify that credit has begun:

InFoRmAtIon mondAY tHRoUgH FRIdAY (8:00 a.m. to 5:00 p.m.)

In State: 1-800-932-4600 tdd: 1-800-228-0676 out-of-State: 1-717-412-5300 tdd out-of-State: 1-717-412-5380

How to Edit Dl 16Lc Form Online for Free

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Step 1: The first step should be to click the orange "Get Form Now" button.

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Fill in the dl, 16, lc PDF by typing in the text required for each individual section.

penndot form dl 16lc gaps to fill out

Inside the segment What, Police, Department purposes, ACKNOWLEDGMENT, PLEASE, PRINT AND, SIGNATURE, IN, INK DATE, and Section, b type in the details that the software asks you to do.

Finishing penndot form dl 16lc part 2

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