Form 5454 - Request To Obtain Interactive Driver Records

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Missouri Department of Revenue

FORM

Request to Obtain Interactive Driver Records

5454

Modification

Please check one:

New

Cancel

Account Name (Must match Security Access Code when applicable)

Date (MM/DD/YYYY)

__ __ / __ __ / __ __ __ __

Physical Address, City, State, and Zip Code

Mailing Address, City, State, and Zip Code

Assigned Department of Revenue Security Code

(Personal information will be redacted if security code is not provided.)

Account Manager

Authorized User Listing (see attached)

Phone Number

Fax Number

(

)

(

)

___ ___ ___

___ ___ ___ ___

___ ___ ___

___ ___ ___ ___

E-mail Address

Financial Institution Name

Phone Number

(

)

___ ___ ___

___ ___ ___ ___

Financial Institution Address (Street, RR, or PO Box Number)

City

State

Zip Code

An original voided check or deposit slip

Account Type (Check only one box)

Checking

Savings

General Ledger

must be attached.

Routing Number

Depositor (Business) Account Number

Under penalties of perjury, I declare that the information I have provided and any attached supplement is true, complete, and correct. I also certify that the

willful and unauthorized access, use or disclosure of information obtained from any Department record may result in award of damages under Title 18

U.S.C. Section 2724, and imposition of penalties as otherwise provided by law. In addition, I acknowledge that I have read and understand the security

requirements and terms of access outlined on page two of this form.

Signature(s) of individual, partner(s) (all required), authorized member or corporate officer, news agent, or government agent

Printed Name(s)

Title of Corporate Officer, News Agent, or Government Agent

Your account and personal identification numbers will be mailed to the address provided above.

Once you have received this information, you may begin ordering driving records.

Form-5454 (Revised 05-2013)

Mail to: Motor Vehicle and Driver Licensing Division

Phone: (573) 526-3669

For additional information visit

P.O. Box 2167

Fax: (573) 526-7367