New York State Department of Motor Vehicles CERTIFICATION OF LOST LICENSE, PERMIT OR PLATES Use this form to explain why you can’t turn in your driver license, learner permit or license plates to DMV. Your license and/or registration may be restored to you after you serve a suspension or revocation period. In most cases, the date you give this form to DMV will begin your compliance with the suspension or revocation. If the effective date of the order is later than the date DMV receives this form, your compliance will begin on that effective date. Instructions: Provide all the information requested below. Please print your name and mailing address exactly as they are printed on your driver license, learner permit or vehicle registration. Put a check in the box next to each of the items below that you can’t turn in to DMV. In the “Explanation” section, explain why you can’t turn in the items that you check. Sign in the “Customer’s Signature” box, and return this form to any DMV office. Filing this form will invalidate the items that you check below (documents and/or license plates). If you find your suspended/ revoked driver license, learner permit or license plates after you give this form to DMV, you must immediately turn in to a DMV office any items that you find. Name __________________________________________________ Mailing Address __________________________________________________ __________________________________________________ __________________________________________________ / / Date of Birth: ____________________________ (Month/Day/Year) Client ID # ______________________________ (or FEIN if a corporation) I am unable to turn in the following item(s) to the Department of Motor Vehicles: Photo Driver License Interim/Temporary Driver License or Learner Permit Learner Permit License Plates (please write the plate number here) ____________________________. A police report or form MV-78B (Report of Lost, Stolen or Confiscated Motor Vehicles Items) must be provided if you have reported the plates stolen, or if both plates have been lost, and the vehicle registration is not yet expired. If one plate has been lost, the remaining plate must be turned in. Vehicle Identification Number ____________________________________ Year _________ Make _____________________ Explanation: _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ Certification: Under the penalty of perjury, I certify that, to the best of my knowledge, the explanation above is true. Customer’s Signature ± WARNING: Date / / FALSE STATEMENTS ARE PUNISHABLE UNDER SECTION 210.45 OF THE PENAL CODE. DRIVING A MOTOR VEHICLE WHILE YOUR LICENSE OR REGISTRATION IS SUSPENDED OR REVOKED IS A MISDEMEANOR, AND IS PUNISHABLE BY LAW. MV-1441.3 (10/07) American LegalNet, Inc. www.FormsWorkFlow.com