Missouri Form 4681 PDF Details

Ensuring the privacy and accuracy of personal information is a critical concern for both individuals and institutions handling sensitive data. The Missouri 4681 form plays a crucial role in this context, serving as a formal request for the release of driver license records or other documents that contain personal details. This requirement ensures that access to such sensitive information is tightly controlled, requiring the record holder's explicit approval. Completion, signature, and notarization of the form are mandatory steps, without which the request will be outright denied, underscoring the rigorous safeguards put in place to protect personal information. The form not only facilitates the retrieval of one's own driving records but also outlines the types of information that can be requested, including both personal and non-personal details. Options for how the records can be sent—whether by mail, fax, or email—are clearly delineated, providing flexibility in how one receives the requested information. Additionally, the form states the associated fees and methods of payment, ensuring transparency in the transaction. By making such provisions, the Missouri Department of Revenue underscores its commitment to privacy, security, and accessibility in handling driver license records.

QuestionAnswer
Form NameMissouri Form 4681
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names Fillable Form 4681 - Request From Record Holder printable ...

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Form

4681

Request From Driver License Record Holder

 

Record holders must approve the release of driver license records or other documents containing personal information. To request such records this form must be completed, signed and notarized or the request will be denied. For a faster and more convenient way to obtain a copy of non-restricted Missouri driver record information visit https://mydmv.mo.gov/ and select Driver License Services, or visit a local license office. Personal information includes the person’s name, address, date of birth, sex, height, weight, eye color, driver license number, social security number, photograph, and telephone number. Non-Personal information may include the person’s first and last name, driving history, and zip code.

Holder’sRecord Information

 

First Name

 

Middle Initial

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (MM/DD/YYYY)

Missouri Driver License or Social Security Number

 

Daytime Telephone Number

 

 

 

 

 

___ ___ / ___ ___ / ___ ___ ___ ___

 

 

 

 

(___ ___ ___)___ ___ ___-___ ___ ___ ___

 

 

Mailing Address

City

State

Zip Code

E-Mail Address

 

 

 

 

 

 

 

 

 

Driver License

Records

 

 

 

 

Mailing & Fax

Information

 

 

Payment Options and Signature

Notary Information

r Driver Record

r Clearance Letter (No Fee Required)

r Image Portfolio (Black and White Photo)

r Temporary Driving Privilege (No Fee Required)

rOther (Specify) _____________________________________________________________________________________

Would you like the requested records to be sent somewhere other than to the record holder’s address? r Yes r No

If yes, how would you like it to be sent? r Mail (provide alternate mailing address) r Fax (add $0.50 per page faxed; provide fax number)

rE-mail ______________________________________

Name

Agency Name (If Applicable)

Fax Number

(___ ___ ___)___ ___ ___-___ ___ ___ ___

Address

City

State

Zip Code

 

 

 

 

Records can be obtained by walk-in, mail-in, or e-mail request. The fee is $2.82 per record. A convenience fee will be charged for credit or debit card transactions. The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds. You may visit us at Central Office, Harry S Truman Building, Room 470, 301 West High Street, Jefferson City, Missouri.

 

 

 

Money

Debit

 

 

American

 

 

 

 

 

Cash

Check

Discover

Visa

Mastercard

 

Total Record Fees

Convenience Fee

 

Order

Card

Express

 

Central Office Visit

 

 

 

 

 

 

 

 

 

$0.00 - $50.00

$1.25

 

 

 

 

 

 

 

 

 

$50.01 - $75.00

$1.75

 

 

 

 

 

 

 

 

 

 

Mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$75.01 - $100.00

$2.15

 

 

 

 

 

 

 

 

 

 

Fax

 

 

 

 

 

 

 

 

 

$100.01 or more

2.15%

 

 

 

 

 

 

 

 

 

 

 

 

If you are paying by credit or debit card you must provide the following:

Name (as it appears on card)

Card Number

Expiration Date

 

 

__ __ / __ __

 

 

 

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I authorize the Department of Revenue to send the requested record where I designated above.

 

 

 

 

 

 

 

Record Holder’s Signature

 

 

Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

___ ___ / ___ ___ / ___ ___ ___ ___

 

 

 

 

 

 

 

 

 

 

 

 

 

Embosser or black ink rubber stamp seal

Subscribed and sworn before me, this

 

 

 

 

 

day of

 

year

 

 

 

 

 

 

 

 

State

County (or City of St. Louis)

 

My Commission Expires (MM/DD/YYYY)

 

 

 

 

 

___ ___ /___ ___ /___ ___ ___ ___

 

 

 

 

 

 

 

 

Notary Public Signature

 

 

 

 

 

 

 

 

 

 

Notary Public Name (Typed or Printed)

 

 

 

 

 

 

 

 

Mail to: Driver License Bureau

Phone: (573) 526-2407

Form 4681 (Revised 06-2021)

 

DL Record Center

Fax: (573) 526-7367

 

P.O. Box 2167

E-mail: dlrecords@dor.mo.gov

Visit https://dor.mo.gov/

Jefferson City, MO 65105-2167

 

for additional information.

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Missouri Form 4681 writing process clarified (step 2)

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