Form 4595 - Application For Limited Driving Privilege
Download a blank fillable Form 4595 - Application For Limited Driving Privilege in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 4595 - Application For Limited Driving Privilege with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Reset Form
Print Form
Missouri Department of Revenue
Form
Application for Limited Driving Privilege
4595
Driver License Number
Date of Birth (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Name (Last, First, Middle Initial)
Social Security Number
|
|
|
|
|
|
|
|
Street Address (Do not use P.O. Box)
City, State, Zip Code
Mailing Address (If different from street address)
City, State, Zip Code
E-mail Address
Phone Number
(
)
-
___ ___ ___
___ ___ ___
___ ___ ___ ___
Applicant is requesting a limited driving privilege for the following reason(s): (Must select at least one box)
r
Employment (Must provide name and address of employer(s) or if self-employed, name and address of business and type of
employment.) ______________________________________________________________________________________
__________________________________________________________________________________________________
r
Education (Must provide the school(s) name and address.)
______________________________________________________
___________________________________________________________________________________________________________
r
Attending a Substance Abuse Traffic Offender Program (SATOP) (Provide name and address of alcohol or drug treatment
program, if known.)
___________________________________________________________________________________________
___________________________________________________________________________________________________________
r
To and from a certified ignition interlock device (IID) service facility
r
Seeking medical treatment
Being unable to operate a motor vehicle will result in a hardship to the applicant because traveling is required:
r
To and from child care (Must provide child care provider(s) name and address.)
____________________________________
___________________________________________________________________________________________________________
r
To and from bank (Must provide the name and address of the bank.)
_____________________________________________
___________________________________________________________________________________________________________
r
To transport child or children to and from school(s) (Must provide the school(s) name and address.)
__________________
___________________________________________________________________________________________________________
r
To transport child or children to and from spousal or guardian visitation (Must provide the address.)
__________________
___________________________________________________________________________________________________________
r
To and from probation officer meetings (Must provide the county where the meetings are held.)
_____________________
___________________________________________________________________________________________________________
r
r
r
T o and from grocery store
To and from gas station
To seek employment between 8 a.m. through 5 p.m.
r
r
r
To and from pharmacy
To and from court
To and from community service
The applicant must have proof of insurance (i.e., SR-22) on file with the Director of Revenue when submitting this application.
Proof of Ignition Interlock Device (IID) service or installation must also be provided if applicable.
Applicant’s Signature
Date of Application (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
If the application is approved, an order granting the limited driving privilege will be mailed to you.
You must carry the original copy of the Limited Driving Privilege Notice with you when operating a motor vehicle.
Form 4595 (Revised 06-2013)
Mail to:
Driver License Bureau
Phone: (573) 751-4475
Visit dor.mo.gov/drivers/ldp.php
P.O. Box 200
Fax: (573) 522-8795
for additional information.
Jefferson City, MO 65105-0200
E-mail: dlbmail@dor.mo.gov
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial