The Missouri 4595 form is an application for a Limited Driving Privilege issued by the Missouri Department of Revenue. This form allows individuals who have lost their driving privileges to request a limited license for specific purposes such as employment, education, or medical treatment. To start the process, fill out the form by clicking the button below.
The Missouri 4595 form, officially known as the Application for Limited Driving Privilege, serves a crucial purpose for individuals seeking the ability to drive under specific circumstances. This form is particularly relevant for those who have had their driving privileges revoked or suspended but need to operate a vehicle for essential activities. Key sections of the form require applicants to provide personal information, including their driver’s license number, date of birth, and social security number, alongside their current address and contact details. Additionally, applicants must indicate the reasons for requesting a limited driving privilege, which can include employment, education, medical treatment, or other essential travel needs. It is important to note that proof of insurance, such as an SR-22, must be submitted along with the application. If the application is approved, the applicant will receive a Limited Driving Privilege Notice, which must be carried while driving. This form not only facilitates necessary transportation but also aims to ensure that individuals can meet their daily obligations despite restrictions on their driving status.
Form
Missouri Department of Revenue
Application for Limited Driving Privilege
4595
Driver License Number
Date of Birth (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Name (Last, First, Middle Initial)
Social Security Number
|
Street Address (Do not use P.O. Box)
City, State, ZIP Code
Mailing Address (If different from street address)
E-mail Address
Phone Number
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Limited Driving Privilege Reasons
Applicant is requesting a limited driving privilege for the following reason(s): (Must select at least one box)
rEmployment (Must provide name and address of employer(s) or if self-employed, name and address of business and type of employment.) ______________________________________________________________________________________
__________________________________________________________________________________________________
rEducation (Must provide the school(s) name and address.) ______________________________________________________
___________________________________________________________________________________________________________
rAttending a Substance Abuse Traffic Offender Program (SATOP) (Provide name and address of alcohol or drug treatment program, if known.) ___________________________________________________________________________________________
rTo and from a certified ignition interlock device (IID) service facility
rSeeking medical treatment
Being unable to operate a motor vehicle will result in a hardship to the applicant because traveling is required:
rTo and from child care (Must provide child care provider(s) name and address.)____________________________________
rTo and from bank (Must provide the name and address of the bank.) _____________________________________________
rTo transport child or children to and from school(s) (Must provide the school(s) name and address.)__________________
rTo transport child or children to and from spousal or guardian visitation (Must provide the address.) __________________
rOTHER ____________________________________________________________________________________________________
r To and from grocery store
r To and from gas station
r To seek employment
rTo and from pharmacyr To and from court obligations r To and from church
The applicant must have proof of insurance (i.e., SR-22) on file with the Director of Revenue when submitting this application. Proof of Ignition Interlock Device (IID) service or installation must also be provided if applicable.
Sign
Applicant’s Signature
Date of Application (MM/DD/YYYY)
If the application is approved, an order granting the limited driving privilege will be mailed to you.
You must carry the original copy of the Limited Driving Privilege Notice with you when operating a motor vehicle.
Mail to:
Driver License Bureau
Phone: (573) 526-2407
Form 4595 (Revised 02-2017)
Visit http://dor.mo.gov/drivers/ldp.php
P.O. Box 200
Fax:
(573) 522-8795
for additional information.
Jefferson City, MO 65105-0200
E-mail: dlbmail@dor.mo.gov
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