Driving Record Abstract Request Form
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Office of the Secretar y of State
2701 S. DIRKSEN PKWY.
SPRINGFIELD, IL 62723
Driver Ser vices Depar tment
217-782-2720
Driving Record Abstract Request Form
All requestors must complete Sections I, II, IV and V.
SECTION I
Enter the Driver’s License Number and/or the Name and Date of Birth of the driver(s) whose record(s) is being requested in the spaces
below. PLEASE PRINT LEGIBLY.
DRIVER’S LICENSE NUMBER
NAME (Last, First, Middle)
DATE OF BIRTH
GENDER
______________________________________
____________________________________
____________________
____________
______________________________________
____________________________________
____________________
____________
______________________________________
____________________________________
____________________
____________
______________________________________
____________________________________
____________________
____________
______________________________________
____________________________________
____________________
____________
SECTION II – REQUESTOR’S IDENTITY
Driver’s License, Permit or ID Number:_____________________________________________________________________________
For yourself: ☐ Yes ☐ No If no, complete Section III.
Name
First
M.I.
Last
________________________________________________________________________________________________________________________________
Residential Address
________________________________________________________________________________________________________________________________
City
State
ZIP Code
SECTION III – If you classified yourself as a representative or agent of anyone other than yourself in Section II, you must provide
the following information. Complete Section IV on reverse.
Name of Person or Organization I am representing
________________________________________________________________________________________________________________________________
Address of Person or Organization
________________________________________________________________________________________________________________________________
City
State
ZIP Code
If the record(s) you requested must be mailed, to which address above should it be mailed: ☐ Section II ☐ Section III
SECTION IV (Please see reverse.)
SECTION V – AFFIRMATION OF REQUESTOR
I affirm that the information in Sections I, II, III and IV are true and correct to the best of my knowledge. I understand that if any
of the information provided by me in these sections is knowingly false or misleading, administrative, civil and/or criminal actions
may be taken against me. (Notarization required if mailing form.)
Notary Seal
Signature: ____________________________________
Date: ____________________
SECRETARY OF STATE USE ONLY
Identification Checked:______________________________________________________________________________________________________
Employee Signature: ______________________________________________________
Date: ________ - ________ - ________
Number of Certified Records:
________ x $12.00 =
________
Type of Record: __________________________________________
Number of Photocopies:
____________ x $ 0.50 =
________
Cash
MO
Check
Credit Card
Number of Certifications:
____________ x $ 2.00 =
________
Printed by authority of the State of Illinois. March 2016 - 1 - DSD DC 164.10
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