Fillable Driving Record Abstract Request Form (Page 2 of 2) in pdf

SECTION IV

Place an “X” in front of the category below that describes you concerning the record(s). Mark only one category per request form.

Items within ( ) are for Secretary of State personnel.

Purpose of Request (This information must be provided if you mark a box that has an asterisk next to it.): ____________________

____________________________________________________________________________________________________________

I AM:

the person named on the abstract requested. (AFF or PUB-FEE “S”)

a law enforcement or court official with an official need for the abstract(s) requested. Complete Section III. (CRT or EXT-NO

FEE “L”)

a private investigative agency or security service licensed in Illinois for any purpose permitted under 625 ILCS 5/2-123 of the

Illinois Vehicle Code. Complete Section III. (PUB-FEE-”H”)

Detective State Registration #: _____________________

the legal representative of the person(s) named on the abstract(s) requested. Complete Section III. (AFF or PUB-FEE-”R”)

Attorney State Registration #: __________________________________________

an attorney not representing the person(s) named on the abstract(s) requested but needing the abstract(s) for legal business

involving the affected driver(s). Complete Section III. (PUB-FEE-”A”)

Attorney State Registration #: ______________________________________

the parent/legal guardian of the minor person(s) (under age 18) named on the abstract(s) requested. I am submitting the

minor’s signed and notarized consent to obtain his/her abstract. (AFF or PUB-FEE-”P”)

an immediate family member (parent/legal guardian, brother, sister, spouse, grandparent, child or grandchild) of the adult (age

18 or older) named on the abstract(s) requested. I am submitting the adult’s signed and notarized consent to obtain his/her

abstract. (PUB-FEE-”F”)

Relationship: _________________________________________

a representative of a local, state or federal government agency, with an official business need for the abstract(s) requested to

carry out the agency function on this request form. Complete Section III. (EXT-NO FEE-”G”)

If an elected official, office held: _________________________________________________

a representative of the insurance industry with a legitimate insurance business need for the abstract(s) requested. Complete

Section III. (PUB-FEE-”I”)

the employer, prospective employer, or representative of the employer or prospective employer of the person(s) named on the

abstract(s) requested. I am submitting the employee’s signed and dated consent form. If I am coming into a facility, I will

bring in the employees signed and dated consent form. The abstract(s) is needed for business purposes pertaining to the

person’s(s’) employment or prospective employment. Complete Section III. (PUB-FEE-”E”)

a representative of a financial institution with a legitimate business need for the abstract(s) requested. Complete Section III.

(PUB-FEE-”B”)

a representative of a new or used vehicle dealership, vehicle rental agency, or tow truck operation with a legitimate business

need for the abstract(s) requested. Complete Section III. (PUB-FEE-”D”)

none of the above. The abstract(s) requested will be mailed to you by the Secretary of State Driver Services Department in

Springfield in approximately 10 business days. The Secretary of State’s office will send a letter to each person for whom a driving

abstract is requested approximately 10 days prior to mailing his/her abstract(s) to you. The letter will inform the person(s) of

the date of your purchase and your name. NOTE: The abstract(s) requested will not list the address or personal information

of the individual(s). (PUB-Fee ”N”)

Driving Record Abstract Request Form Page 2