Form 4681 - Missouri Department Of Revenue
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Form
Missouri Department of Revenue
4681
Request From Driver License Record Holder
Complete this form to request Driver License records (including your personal information on those records).
First Name
Middle Initial Last Name
Date of Birth (MM/DD/YYYY)
Missouri Driver License Number
Daytime Telephone Number
(
)
-
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ ___
___ ___ ___
___ ___ ___ ___
Mailing Address
City
State
Zip Code
r
r
Driver Record
Clearance Letter (No Fee Required)
r
r
Image Portfolio (Black and White Photo)
Temporary Driving Privilege (No Fee Required)
r
Other (Specify) _____________________________________________________________________________________
r
r
Would you like the requested records to be sent somewhere other than to the record holder’s address?
Yes
No
r
r
If yes, how would you like it to be sent?
Mail (provide alternate mailing address)
Fax (add $0.50 per page faxed; provide fax number)
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 $5.88 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
Total Record Fees
Convenience Fee
Cash
Check
Discover
Visa
Mastercard
Order
Card
Express
$0.00 - $50.00
$1.25
Central Office Visit
$50.01 - $75.00
$1.75
Mail
$75.01 - $100.00
$2.15
$100.01 or more
2.15%
Fax or E-Mail
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)
___ ___ / ___ ___ / ___ ___ ___ ___
Subscribed and sworn before me, this
Embosser or black ink rubber stamp seal
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)
Form 4681 (Revised 02-2015)
Mail to:
Driver License Bureau
Phone: (573) 526-3669
DL Record Center
Fax: (573) 526-7367
Visit
P.O. Box 2167
E-mail:
dlrecords@dor.mo.gov
for additional information.
Jefferson City, MO 65105-2167
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