Free Activity Hold Request - Massachusetts

P.O. Box 55889 Boston, MA 02205
RACHEL KAPRIELIAN
REGISTRAR

REQUEST FOR ACTIVITY HOLD ADD/REMOVE
DATE :____________________ LICENSE / ID NUMBER____________________________ I __________________________________(name), hereby request the RMV to Add / Remove (circle one) an activity hold on my Massachusetts Drivers License/ID No. __________________________________. The reason for my request is based on: _____ My identification has been lost or stolen (circle one) and as a result I am concerned that someone may attempt to perform Registry transactions fraudulently with it. _____ I have information that someone actually acquired a document from the RMV using my personal information. Refer to record Number _______________________________________________ CHECK ONE: I do ____ I do NOT know ______ the actual name of the person who may have committed fraud using my name or personal information. If known, s/he is: Name ________________________Address__________________________________________ ______ Other reason: please explain _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I understand that an Activity Hold will prevent future license/ID transactions. I understand that it will be necessary for me to contact Enforcement Services at the above number in order to arrange any future license/ID transactions to be performed and that I will be required to provide additional information and/or identification in order for any transaction to be processed. Should an application for license/ID be submitted in the future, I want to be contacted @ _______________________to confirm or deny the legitimacy of the request. I can provide the following identification or information to substantiate my identification. Available documents: ___________________________________________________________________ My employer is ____________________________ My work phone number is _____________________ My cell phone number is ________________________ My fax number is _______________________

My current address is ___________________________________________________________________ Signature ___________________________________ Print Name________________________________ Social Security No.___________________________ Case #____________________________________