Form Dr 4678 - Request For Waiver - Restrictions On Public Benefits

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DR 4678 (09/27/06)
COLORADO DEPARTMENT OF REVENUE
REQUEST FOR WAIVER - RESTRICTIONS ON PUBLIC BENEFITS
APPLICANT
Current Name - Last
First
Middle
Full Maiden Name, if applicable
Birth Date
Gender
Social Security Number
Current Residence Address - Street
City
State
ZIP Code
U. S. Citizen?
If No, Lawfully Present?
Yes
No
Yes
No
Applicant's Signature
Date
Form(s) of Identifi cation
IF AN APPLICANT IS UNABLE TO PRODUCE THE DOCUMENTATION NECESSARY TO OBTAIN A
COLORADO DRIVER'S LICENSE OR IDENTIFICATION CARD, THE APPLICANT SHALL PROVIDE ANY
AVAILABLE DOCUMENTS THAT VERIFY NAME AND PROOF OF LAWFUL PRESENCE.
REPRESENTATIVE DESIGNATION (IF APPLICABLE)
APPLICANTS LACKING SUFFICIENT MENTAL OR PHYSICAL ABILITY
TO EITHER SIGN THIS FORM OR APPEAR IN PERSON TO SUBMIT THE
FORM MAY ACT THROUGH A DESIGNATED REPRESENTATIVE.
DESIGNATED REPRESENTATIVE
Name - Last
First
Middle
Form(s) of Identifi cation
Identifi cation Number
Applicant's specifi c reason for needing a designated representative
APPLICANT'S DESIGNATED REPRESENTATIVE MUST SIGN BELOW
Signature
Date
THIS FORM AND ALL SUPPORTING DOCUMENTATION MUST BE PRESENTED IN
PERSON AT ONE OF THE FOLLOWING DRIVER'S LICENSE OFFICES:
Craig
Hot Sulphur Springs
Meeker
Steamboat Springs
Alamosa
Delta
Grand Junction
Montrose
Sterling
Denver (Athmar)
Aurora
Durango
Greeley
Northglenn
Trinidad
Boulder
Ft. Collins
Gunnison
Parker
Walsenburg
Canon City
Ft. Morgan
La Junta
Pueblo
Frisco
Lamar
Rangely
Colorado Springs
Glenwood Springs
Longmont
Salida
Cortez

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