Form Dl-54b - Photo Identification Card Application For Change/correction/replacement/renew -
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2DL-54B (2-11)
PHOTO IDENTIFICATION CARD
APPLICATION FOR CHANGE/CORRECTION/REPLACEMENT/RENEW
Bureau of Driver Licensing
P.O. Box 68272
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION
Harrisburg, PA 17106-8272
CHECK APPLICABLE BLOCK:
1.
REPLACEMENT (DUPLICATE) — Complete Sections A, B, C (if applicable), D and E (if applicable). All requests must be notarized.
2.
RENEWAL, CHANGE or CORRECTION — Complete Section A, C (if applicable), D and E (if applicable). Notarization is not required.
YOU MUST COMPLETE ALL PARTS OF SECTION A
A
DRIVER’S LICENSE NUMBER
LAST NAME
JR./ETC
FIRST NAME
MIDDLE NAME
TELEPHONE NUMBER (
E-MAIL ADDRESS (if applicable)
8:00A.M. - 4:30P.M.)
DATE OF BIRTH
MONTH
DAY
YEAR
B
ORGAN DONOR DESIGNATION
REASON REPLACEMENT REQUIRED: (Check One):
ADD
LOST
STOLEN
NEVER RECEIVED
OTHER
(Parental consent in Section E required if under 18)
MUTILATED
CHANGE
CORRECTION
REMOVE
C
CHANGE OR CORRECTION ONLY (Important information on reverse side)
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. See reverse if using an out-of-state address.
NEW
STREET
ADDRESS
PA
STATE
ZIP CODE
CITY
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.
NAME CHANGE
REASON:
MARRIAGE
DIVORCE
OTHER (see reverse side)
MIDDLE NAME
JR., ETC.
FIRST NAME
LAST
OTHER CHANGES
EYE COLOR
(Please check one):
BLUE
BROWN
GREEN
HAZEL
PINK
BLACK
GRAY
DICHROMATIC
OTHER __________________
_____________________________________________________________________________________________________________________________________________________________________________________
CORRECTION OF DATE OF BIRTH
SOCIAL SECURITY NUMBER
HEIGHT
MONTH
DAY
YEAR
FEET
INCHES
D
AUTHORIZATION AND CERTIFICATION (SIGN AND ENTER FEE)
I certify under penalty of law that all information given on this application is true and correct. I hereby authorize
FEE PAID
the Social Security Administration to release to the Department of Transportation Information concerning my
Send Check
$
Social Security Identification Number for the purpose of Identification. If using a Messenger Service, I hereby
In This Amount
authorize the Department to furnish them with my driving record for the purpose of processing this form.
(fee information on back)
I am under the age of 18 years and I hereby request organ donor designation on my Pennsylvania I.D. card. Parental consent in Section E is required.
Applicants 18 years of age or older will have the opportunity to request Organ Donor designation at the photo center at the time they have their
photo taken.
I wish to contribute $1.00 to the Organ Donation Awareness Trust Fund (see reverse). If checked here, include the additional $1.00 in the amount entered in
the Fee Paid block above.
WARNING: Misstatement of fact is a misdemeanor
X
SIGN
of the third degree punishable of up to $2,500 and/
HERE
or imprisonment up to 1 year (18 Pa C.S. Section
Applicant's Signature in Ink
(Date)
4904(b)).
CONSENT OF PARENT, GUARDIAN, PERSON IN LOCO PARENTIS OR SPOUSE AT LEAST 18 YEARS OF AGE. Complete if Applicant is
E
Less Than 18 Years of Age to give consent for Applicant's request for Organ Donor designation.
I hereby certify that I am a
Person in Loco Parentis, or
Spouse at least 18 years of age, and
Parent,
Guardian,
I
Do give consent
Do not give consent for applicant's request for Organ Donor designation.
SUBSCRIBED AND
SWORN TO BEFORE ME
MO.
DAY
YEAR
(Signature of Parent, Guardian, Person in Loco Parentis or
(Date)
Spouse at least 18 years of age-In Ink)
SIGNATURE OF PERSON ADMINISTERING OATH
AFFIDAVIT:
This section must be notarized when applying for a
S
replacement (duplicate) Pennsylvania Identification Card. You are entitled to a free
E
replacement ONLY if this application is completed within 90 days of the original
SIGN IN PRESENCE OF NOTARY
A
date of issuance and the original was never received due to loss in the mail.
L
SEE REVERSE SIDE FOR IMPORTANT INFORMATION
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