Form 4568 - Confidential Record Request

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Missouri Department of Revenue
Form
4568
Confidential Record Request
You may complete this form to request that your driver or motor vehicle registration record(s) remain confidential. This may require you to provide additional
proof of identification, ownership, or registration if you are stopped by law enforcement. The Department may also request this verification annually.
No one will have access to your motor vehicle records except for use by any government agency, including any court or law enforcement agency, in carrying
out its functions, or any private person or entity acting on behalf of a federal, state, or local agency in carrying out its functions.
Each time you title, register, or sell a vehicle, you must complete and submit this form and the appropriate application to the Motor Vehicle Bureau so your
record(s) can be updated accordingly. You are not required to use this form when you renew your registration if you use the confidential renewal notice the
Department issues to you.
Name (Last, First, and Middle Initial)
Driver License Number or SSN
ORI Number (if peace officer)
Street Address
City
State
Zip Code
Date of Birth (MM/DD/YYYY)
Agency Name
Position or Title of Officer
Daytime Telephone Number
__ __ / __ __ / __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
If applicant is other than officer, provide officer’s name and date of birth
Previous Name (if applicable)
Relationship to Officer
__ __ / __ __ / __ __ __ __
Pursuant to Section 32.056 RSMo,
Position of Applicant or Family Member (select one)
I certify that (select one):
r
r
county, state, or federal parole officer
person vested by Article V, Section 1 of the
Missouri Constitution with judicial power of
r
r
federal pretrial officer
I am currently a, or
the state
r
member of the federal judiciary
r
I am an immediate family member of a
r
peace officer
Record(s) you wish to be confidential:
Also attach a copy of the applicant’s official employment credentials or a letter, dated within the last
r
Driver Record
30 days, from the employing agency, which verifies employment and position. If the applicant on this
r
form is an immediate family member, a copy of the officer’s employment credentials must be attached
Vehicle Registration Record(s)
(Complete vehicle section below)
to this form.
Record(s) you wish to remove the confidential status from:
This form must be presented to a Missouri Motor Vehicle and Driver
r
Driver Record
License office in person to remove a confidential status from your
dor.mo.gov/mvdl/offloc
record(s). Visit
to locate an office near you. A
r
Vehicle Registration Record(s) (Complete vehicle section below)
faxed or mailed request will not be accepted. Identity and employment
r
Temporarily remove the driver license confidential status.
credentials of the applicant must be verified. If the applicant on this form
(Status will be re added after transaction completed)
is an immediate family member, the officer must accompany the applicant
r
Permanently remove the confidential status on the driver record
to the license office as both identities must be verified.
and on the vehicles below (Complete vehicle section below)
Attach a list of vehicles if necessary.
Current License
Expiration
Year
Make
Vehicle Identification Number
Plate Number
Year
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Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I further declare that when I
discontinue being a county, state, or federal parole officer, federal pretrial officer or peace officer for any reason, I will notify the Department of Revenue.
Applicant Signature
Typed or Printed Name
Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
If applicant is an immediate family member of an officer, officer must sign here. Typed or Printed Name
Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
For License Office Use Only
I have verified the identity of the applicant and of the officer,
For Central Office Use Only
if applicant was other than officer.
Clerk ID Number
Office Number
Processed By:
Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
Form 4568 (Revised 11-2013)
Mail to: Motor Vehicle Bureau
Phone: (573) 526-1743
dor.mo.gov/mvdl/offloc/
Visit
Fax: (573) 751-3551
P.O. Box 2076
to view a list of office locations near you.
Jefferson City, MO 65105-2076
E-mail:
mvbmail@dor.mo.gov

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