Free Request to withhold name and address - Wisconsin


File Size: 46.5 kB
Pages: 1
File Format: PDF
State: Wisconsin
Category: Government
Author: WisDOT
Word Count: 399 Words, 2,528 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dot.wisconsin.gov/drivers/forms/mv3592.pdf

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REQUEST TO WITHHOLD NAME AND ADDRESS
s.341.08(1m), 342.06(1)(i), 343.14(2m) Wis. Stats. Wisconsin Department of Transportation MV3592 11/2006

Statement of purpose/effect Under Wisconsin law, the Department of Transportation, Division of Motor Vehicles is required to provide information from its records to requesters. This information may be used for marketing purposes. If you do not want your name and address included in requests for 10 or more records, complete and return this form. This form will not eliminate mailings that originate from other sources of information used by marketers. Certain requesters are authorized by law to receive your name and address upon request provided such information is used for the purpose of: * writing and renewing insurance policies and related underwriting; * billing and paying of insurance claims; * vehicle safety recall notification programs; and * law enforcement activities. A request to withhold name and address is limited to individuals. If a vehicle is jointly owned, only the owner making the request is affected. Once a request is processed, the designation will remain in effect until the person asks the department to remove it. Mail completed form to: Wisconsin Dept. of Transportation PO Box 7983 Madison, WI 53707-7983

If you have additional questions, please write to the above address or call 608-266-1466 for vehicle registration information or 608-266-2353 for driver license information. Instructions: To request withholding of your name and address from driver license, vehicle registration, or identification cards for the physically disabled records, please provide the following information. The social security number will be used to verify the identification of the applicant and will not be used for any other purpose. Use of this form is limited to one person.
Clear Form

Please print legibly. Provide COMPLETE information. The following information is REQUIRED.
Name - First, Middle, Last - As Shown on Driver License or Vehicle Record Birth Date

Residence Street Address, City, State, ZIP Code

Today's Date

Incomplete or illegible forms will not be processed.
Driver License Number, If Applicable Social Security Number

Please check ALL that apply. I have moved. Please record my new residence address as shown above.

I do not want my name and address provided from the Wisconsin Department of Transportation Driver or Vehicle records.

I previously requested withholding of my name and address, but want to reverse that designation.

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