Form 4595 at a glance
What it is: Form 4595 is the Missouri Department of Revenue Application for Limited Driving Privilege.
Where and when to file: Mail to: Driver License Bureau, P.O. Box 200, Jefferson City, MO 65105-0200.
A filled-in Form 4595 example: a clerk asks for a limited driving privilege
How to fill out Form 4595, box by box
Name and address
Enter the Driver License Number and the Date of Birth (MM/DD/YYYY).
Enter the Name (Last, First, Middle Initial) and the Social Security Number.
Enter the Street Address (Do not use P.O. Box) and the City, State, ZIP Code.
Enter the Mailing Address (If different from street address) and its City, State, ZIP Code.
Enter the E-mail Address and the Phone Number.
Limited driving privilege reasons
The applicant is requesting a limited driving privilege for the following reason(s): must select at least one box.
Employment: Must provide name and address of employer(s) or if self-employed, name and address of business and type of employment.
Education: Must provide the school(s) name and address.
Attending a Substance Abuse Traffic Offender Program (SATOP): Provide name and address of alcohol or drug treatment program, if known.
To and from a certified ignition interlock device (IID) service facility.
Seeking medical treatment.
Hardship because traveling is required
Being unable to operate a motor vehicle will result in a hardship to the applicant because traveling is required:
To and from child care: Must provide child care provider(s) name and address.
To and from bank: Must provide the name and address of the bank.
To transport child or children to and from school(s): Must provide the school(s) name and address.
To transport child or children to and from spousal or guardian visitation: Must provide the address.
To and from grocery store, to and from gas station, to seek employment.
To and from pharmacy, to and from court obligations, to and from church.
Signing and the date of application
Sign on the Applicant's Signature line and enter the Date of Application (MM/DD/YYYY).
The applicant must have proof of insurance (i.e., SR-22) on file with the Director of Revenue when submitting this application. Proof of Ignition Interlock Device (IID) service or installation must also be provided if applicable.
More rules for Form 4595
If the application is approved, an order granting the limited driving privilege will be mailed to you. You must carry the original copy of the Limited Driving Privilege Notice with you when operating a motor vehicle.
Common questions about Form 4595
Where do I file it?
Mail to: Driver License Bureau, P.O. Box 200, Jefferson City, MO 65105-0200.
Sources
[1] Form 4595, Application for Limited Driving Privilege, Missouri Department of Revenue (the Official source link on this page).