Form 4676 - Affidavit Of Lost/destroyed/stolen License/ Affidavit To Confirm Identification
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MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU
P.O. BOX 200
JEFFERSON CITY MO 65105-0200
FORM
TELEPHONE: (573) 751-2730
FAX: (573) 751-2722
4676
AFFIDAVIT OF LOST/DESTROYED/STOLEN LICENSE/
AFFIDAVIT TO CONFIRM IDENTIFICATION
(REV. 05-2013)
I, _________________________________________________________________________ , do hereby swear or affirm on my oath,
that I was born on the ___________ day of ______________________________ , YEAR __________ , and that my Social Security
Number is _____________________ .
Further, I swear or affirm that:
My license has been: Lost, Destroyed or Stolen (circle one)
The photo or image shown to me at the ____________________________________________________________ License Office
(IS, IS NOT) my photo or image. (circle one)
I (DO, DO NOT) know that person. (circle one)
I (DO, DO NOT) know how that person was able to obtain my identification documents to enable him or her to impersonate me.
(circle one)
Information regarding the person who impersonated me is as follows:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Further, I am substantiating my identification to be true and authentic by presenting the following documents:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Further, this affidavit is accompanied by photocopies of the documents listed above, the originals of which were witnessed by license
office personnel.
Based on the information above, I am making application for a:
Driver License
Nondriver License
Permit
PLACE OF EMPLOYMENT
WORK TELEPHONE
HOME TELEPHONE
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
MAIL DRIVER/NONDRIVER LICENSE/PERMIT TO:
ADDRESS SHOWN ON LICENSE DOCUMENT
OTHER (PLEASE INDICATE BELOW):
STREET ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
I hereby certify under penalty of perjury, that all information regarding request is true and accurate and is made without intent to defraud.
SIGNATURE
DATE (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
NOTARY INFORMATION
NOTARY PUBLIC EMBOSSER OR
STATE
COUNTY (OR CITY OF ST. LOUIS)
BLACK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
YEAR
USE RUBBER STAMP IN CLEAR AREA BELOW
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
Form 4676 (Revised 05-2013)
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