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MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE BUREAU — RECORD CENTER
FORM
PO BOX 2167, JEFFERSON CITY MO 65105-2167
1745
(573) 526-3669
FAX: (573) 526-7367
REQUEST FOR INFORMATION
(REV. 05-2013)
REQUESTER INFORMATION
NAME
SECURITY ACCESS CODE (IF APPLICABLE)
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
(
)
(
)
SUBJECT INFORMATION
NAME AS IT APPEARS ON SUBJECT’S CURRENT MISSOURI DRIVER LICENSE/RECORD
MISSOURI CLASSIFIED LICENSE NUMBER
ADDRESS AS IT APPEARS ON SUBJECT’S CURRENT MISSOURI DRIVER LICENSE/RECORD
SUBJECT’S DATE OF BIRTH
CITY
STATE
ZIP CODE
RECORD(S) REQUESTED
I HEREBY REQUEST THE FOLLOWING RECORD (PLEASE MARK THE APPROPRIATE BOX(ES):
DRIVER RECORD*
IMAGE PORTFOLIO (LICENSE PHOTO)
CASE HISTORY*
HARDSHIP PACKAGE
A CASE HISTORY CONSISTS OF ANY OPEN CASE OR ANY REINSTATEMENT
A HARDSHIP PACKAGE CONSISTS OF A CERTIFIED DRIVER
OR TERMINATION CASE NOT LESS THAN TWO YEARS OLD.
RECORD AND A CERTIFIED SR-22.
CASE DOCUMENT (SPECIFY)*
OTHER (SPECIFY) __________________________________
REINSTATEMENT NOTICE
SUSPENSION NOTICE
_________________________________________________
CONVICTION (TICKET# ____________________)
_________________________________________________
SR-22
_________________________________________________
*RECORDS MAY BE CERTIFIED
PLEASE SEND THE ABOVE RECORD(S) BY
MAIL
FAX (add $0.50 per page faxed)
CHECK IF CERTIFIED RECORD REQUESTED
and/or
PAYMENT OPTIONS
CENTRAL
TOTAL RECORD FEES
CONVENIENCE FEE
PAYMENT
Records can be
FAX OR
MAIL
OFFICE
OPTIONS
E-MAIL
obtained by walk-in,
$0.00-$33.00
$1.00
VISIT
mail-in, or e-mail
$33.01-$100.00
3.00%
CASH
a
request,
$100.01-$250.00
2.95%
CHECK
a
a
$250.01-$500.00
2.85%
MONEY ORDER
a
a
The fee is $5.88
per record.
DEBIT CARD
a
a
$500.01-$750.00
2.85%
DISCOVER
a
a
a
$750.01-$1,000.00
2.80%
A convience fee
VISA
a
a
a
$1,000.01-$1,500.00
2.75%
will be charged for
AMERICAN EXPRESS
a
a
a
$1,500.01-$2,000.00
2.70%
credit/debit card
transactions.
MASTERCARD
a
a
a
$2,000.01 or more
2.60%
Mail to: Motor Vehicle and Driver Licensing Division-Record Center, PO Box 2167, Jefferson City, MO 65105-2167 Fax or E-Mail to: 573 526-7367 dlrecords@dor.mo.gov
Visit at: Central Office, Harry S Truman Building, Room 370, 301 West High Street, Jefferson City, MO
NAME (AS IT APPEARS ON CARD)
CARD TYPE
CARD NUMBER
EXPIRATION DATE
__ __ / __ __
REQUESTER’S NAME
REQUESTER’S SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
THE MISSOURI DEPARTMENT OF REVENUE MAY ELECTRONICALLY RESUBMIT CHECKS RETURNED FOR INSUFFICIENT OR UNCOLLECTED FUNDS
DOR-1745 (05-2013)