Form 4170 - Certified Records Information Request
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Missouri Department of Revenue
Form
4170
Certified Records Information Request
Name of Organization
Security Access Code (if applicable)
Address
City
State
Zip Code
Telephone Number
Fax Number
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E-mail Address
Name (Last, First, and Middle Initial)
Social Security Number
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Driver’s License Number
Date of Birth (MM/DD/YYYY)
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Please send the documents as checked below:
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Certified copy of driving record only.
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Certified copy of driving record and most recent Notice of Suspension or Revocation.
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Convictions (As specified)
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BAC Convictions and DWI Convictions.
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Case (Indicate each case number requiring certification).
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Each case includes all letters, court orders and convictions.
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Other
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Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Requester’s Signature
Title
Requester’s Printed Name
Date (MM/DD/YYYY)
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Form 4170 (Revised 09-2013)
Mail to:
Motor Vehicle Bureau
Phone: (573) 526-4400
Visit
Records Center
Fax: (573) 751-8646
for additional information.
P.O. Box 2167
E-mail:
dlrecords@dor.mo.gov
Jefferson City, MO 65105-2167
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