Form Dl-122 - Request For Letter Of Clearance
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1DL-130 (7-17)
REQUEST FOR
LETTER OF CLEARANCE
Dear Customer:
In order to process your request for a letter of clearance on your Pennsylvania driver license, we
require the following information and a $10.00 processing fee:
Name: ________________________________________________________________________
PA Driver No.: __________________________________________________________________
Date of Birth: ___________________________________________________________________
Last PA Address: ________________________________________________________________
______________________________________________________________________________
Current Mailing Address:
______________________________________________________________________________
Customer Telephone No.: ____________________________________
Signature: X ______________________________________________
Please return this form with your check or money order made payable to the Pennsylvania
Department of Transportation.
Sincerely,
Kara N. Templeton, Director
Bureau of Driver Licensing
Attach your check or money order and send to:
Department of Transportation
Bureau of Driver Licensing
Driver Record Services
P.O. Box 68695
Harrisburg, PA 17106-8695
Visit us at or call us at:
In state: 1-800-932-4600 ♦ TDD: 1-800-228-0676 ♦ Out-of-State 1-717-412-5300 ♦ TDD Out-of-State: 1-717-412-5380
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