Form 4595 at a glance
What it is: Form 4595 is the Application for Limited Driving Privilege.
Where and when to file: Mail to: Driver License Bureau, P.O. Box 200, Jefferson City, MO 65105-0200.
What to bring and attach to Form 4595
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.
A filled-in Form 4595 example: a driver asks for work and bank trips
How to fill out Form 4595, box by box
Driver License Number, name and address
Enter the Driver License Number, the Date of Birth (MM/DD/YYYY), 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 the City, State, ZIP Code.
Enter the E-mail Address and the Phone Number.
Limited Driving Privilege Reasons
Select at least one box for the reason you are requesting a limited driving privilege.
Employment: you must provide name and address of employer(s) or if self-employed, name and address of business and type of employment.
If Education, you 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: you must provide child care provider(s) name and address.
To and from bank: you must provide the name and address of the bank.
To transport child or children to and from school(s): you must provide the school(s) name and address.
To transport child or children to and from spousal or guardian visitation: you must provide the address.
OTHER. 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
Sign on Applicant's Signature and enter the Date of Application (MM/DD/YYYY).
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.
Phone: (573) 526-2407. Fax: (573) 522-8795. E-mail: dlbmail@dor.mo.gov.
Visit http://dor.mo.gov/drivers/ldp.php for additional information.
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 (Revised 02-2017), Application for Limited Driving Privilege, Missouri Department of Revenue (the Official source link on this page).