Form 4811 - Parental/guardian Request To Deny Or Reinstate Driver License
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TELEPHONE
(573) 751-1887
MISSOURI DEPARTMENT OF REVENUE
FAX
(573) 522-8174
FORM
DRIVER LICENSE BUREAU
4811
Email
dlbmail@dor.mo.gov
P.O. BOX 200
JEFFERSON CITY, MO 65105-0200
(REV. 03-2010)
PARENTAL/GUARDIAN REQUEST TO DENY OR REINSTATE DRIVER LICENSE
CHILD’S LAST NAME
FIRST
MIDDLE INITIAL
CHILD’S DATE OF BIRTH
CHILD’S STREET ADDRESS
CHILD’S LICENSE / PERMIT OR SOCIAL SECURITY NUMBER
CITY
STATE
ZIP CODE
REQUEST TO DENY
I/WE HEREBY CERTIFY THAT:
I am the sole legal custodial parent or legal guardian of the above OR
We are the joint legal custodial parents or legal guardians
referenced child (requires the signature of custodial parent or
of the above referenced child (requires the signatures of
guardian).
both custodial parents or guardians).
1. The above referenced child is not an emancipated minor.
2. I/We request the Director of Revenue to deny issuance of a driver license to the above referenced child pursuant to Section 302.060(12),
RSMo. In the case that a driver license has already been issued, I/we request that the Director of Revenue deny a driving privilege to the
above referenced child.
3. I/We understand that the above referenced child’s driving privilege will be denied until such time that I/we request the Director of Revenue
to reinstate the driving privilege, or until the above referenced child reaches the age of 18.
REQUEST TO REINSTATE
I/WE HEREBY CERTIFY THAT:
I am the sole legal custodial parent or legal guardian of the above OR
We are the joint legal custodial parents or legal guardians
referenced child (requires the signature of custodial parent or
of the above referenced child (requires the signatures of
guardian).
both custodial parents or guardians).
1. I/We previously requested the Director of Revenue to deny the driving privilege of the above referenced child.
2. I/We request the Director of Revenue to reinstate the driving privilege of the above referenced child pursuant to Section 302.060(12), RSMo.
3. I/We understand that the above referenced child’s driving privilege will be cleared for issuance or return of a license.
I/WE FURTHER CERTIFY, under penalty of perjury and Chapter 302, RSMo, that the foregoing information is true and this certified statement
is made without intent to defraud.
PARENT(S)’ OR GUARDIAN(S)’ LAST NAME
FIRST
MIDDLE INITIAL
PARENT(S)’ OR GUARDIAN(S)’ LAST NAME
FIRST
MIDDLE INITIAL
DATE OF BIRTH
DRIVER LICENSE NUMBER
DATE OF BIRTH
DRIVER LICENSE NUMBER
STREET ADDRESS
STREET ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
HOME TELEPHONE NUMBER
WORK TELEPHONE NUMBER
HOME TELEPHONE NUMBER
WORK TELEPHONE NUMBER
PARENT(S)’ OR GUARDIAN(S)’ SIGNATURE
DATE
PARENT(S)’ OR GUARDIAN(S)’ SIGNATURE
DATE
®
®
VISIT OUR WEB SITE AT
MO 860-2895 (03-2010)
DOR-4811 (03-2010)
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