142 REQUEST FOR CANCELLATION OR SURRENDER OF A DRIVER LICENSE ...

DEPARTMENT OF MOTOR VEHICLES

142

REQUEST FOR CANCELLATION OR

SURRENDER OF A DRIVER LICENSE OR

IDENTIFICATION CARD

STATE OF CALIFORNIA

?

A Public Service Agency

DMV USE ONLY

Doubled From

To

Name oF persoN as showN oN The liceNse or iDeNTiFicaTioN carD To be caNcelleD

Information about

the document

being cancelled

or surrendered

aDDress

ciTY

liceNse or iD carD NUmber To be caNcelleD

DaTe oF birTh

sTaTe

locaTioN oF liceNse

lost/destroyed

Voluntary surrender i voluntarily surrender and request the cancellation of my:

or cancellation of

reason for the cancellation or surrender:

a DL or ID Card

is the license in the minor¡¯s possession?

is there a change in custody of the minor?

Yes

Yes

Zip coDe

attached

Driver license (Dl) or

other (explain on reverse)

identification card (iD)

No

No

Person cancelling

minor child¡¯s

i certify under penalty of perjury under the laws of the state of california that: (check one)

application or

i signed the minor¡¯s application for a license.

driver license

i did not sign the application but i gave written consent to the issuance of the minor¡¯s license.

i did not sign the application but now have custody of the minor.

priNT YoUr Name

Signature

of person

completing

the form

DMV Employee

siGNaTUre

DaTe

X

aDDress

siGNaTUre oF emploYee aND iD NUmber

oFFice NUmber

DaTe

X

Dl 142 (reV. 12/2014) WWW

CUT ON LINE AND KEEP THIS PART FOR YOUR RECORDS

DEPARTMENT OF MOTOR VEHICLES

142

REQUEST FOR CANCELLATION OR

SURRENDER OF A DRIVER LICENSE OR

IDENTIFICATION CARD

STATE OF CALIFORNIA

?

A Public Service Agency

DMV USE ONLY

Doubled From

To

Name oF persoN as showN oN The liceNse or iDeNTiFicaTioN carD To be caNcelleD

Information about

the document

being cancelled

or surrendered

aDDress

ciTY

liceNse or iD carD NUmber To be caNcelleD

DaTe oF birTh

sTaTe

locaTioN oF liceNse

lost/destroyed

Voluntary surrender i voluntarily surrender and request the cancellation of my:

or cancellation of

reason for the cancellation or surrender:

a DL or ID Card

is the license in the minor¡¯s possession?

is there a change in custody of the minor?

Yes

Yes

Zip coDe

attached

Driver license (Dl) or

other (explain on reverse)

identification card (iD)

No

No

Person cancelling

minor child¡¯s

i certify under penalty of perjury under the laws of the state of california that: (check one)

application or

i signed the minor¡¯s application for a license.

driver license

i did not sign the application but i gave written consent to the issuance of the minor¡¯s license.

i did not sign the application but now have custody of the minor.

priNT YoUr Name

Signature

of person

completing

the form

DMV Employee

Dl 142 (reV. 12/2014) WWW

siGNaTUre

DaTe

X

aDDress

siGNaTUre oF emploYee aND iD NUmber

oFFice NUmber

X

Print

Clear Form

DaTe

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