Form Dl-16lc - Acknowledgment Of Suspension / Revocation / Disqualification / Cancellation Template

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DL-16LC (7-10)
Acknowledgment oF SUSPenSIon/
ReVocAtIon/dISQUAlIFIcAtIon/cAncellAtIon
AS ReQUIRed UndeR SectIon 1541 oF tHe VeHIcle code
Bureau of Driver Licensing
PleASe tYPe oR PRInt In BlUe oR BlAck Ink All InFoRmAtIon
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 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 or credit will not be given.
A
lASt NAme
JR.,etc.
fiRSt NAme
middle NAme
pA dRiVeR'S liceNSe/peRmit NumBeR
dAte of BiRtH (must be listed)
telepHoNe NumBeR
e-mAil AddReSS (if applicable)
month
day
year
change or correction onLY
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.
New
StReet
AddReSS
city
StAte
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.
B
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:
Expired
Lost
Stolen
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): _______________________________________________________________________________________________
_________________________________________________________________________________________________________
C
Acknowledgment
I, ____________________________________ hereby acknowledge that my driving privilege is Suspended/Revoked/Disqualified in Pennsylvania.
PLEASE PRINT
And
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.
X
___________________________________________________________________________________
__________________________________
SIGNATURE IN INK
DATE
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)).
D
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

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