POLICE SECRETARY OF STATE VEHICLE REGISTRATION AND/OR TITLE REVOCATION REQUEST 3650 Winchester Rd. Springfield, IL 62707 FAX: 217-782-2896 (Please print clearly or type) TYPE OF REVOCATION (check one): J License plates only J Title only License Plates Number: Vehicle Identification Number: Title Number: Vehicle Make: Vehicle Year: Last Name: First Name: Middle Initial: Last Name: First Name: Middle Initial: City: Address: State: ZIP Code: Driver’s License Number: Telephone Number: REASON FOR REVOCATION (check one): J Vehicle sold with plates J New owner failed to transfer title (Title revocation only) J Owner moved out of state J Divorce (Clear copy of divorce decree required) J Plates lost, destroyed or disposed of J Owner deceased (Clear copy of death certificate required) J Vehicle donated to charity J Non-possession of plates J Vehicle towed/junked with plates J Vehicle/plates stolen (Clear copy of police report required) J Vehicle repossessed REGISTERED OWNER’S SIGNATURE(S): (Signatures of all registered and/or titled owners are required. Leased vehicles must include the lessor’s signature before request is accepted.) ___________________________________________________ _____________________________________________ Registered owner’s signature ___________________________________________________ Date _____________________________________________ Registered owner’s signature Date Each request must include the correct owner and vehicle information, reason for revocation and signature(s) of the registered owner(s). Failure to include this information will prevent the request from being processed. Vehicle registration and/or title revocation does not remove your name from the record. Please mail or fax to the address above. Printed by authority of the State of Illinois. October 2008 — SOS DOP 159.6 American LegalNet, Inc. www.FormsWorkflow.com