142

REQUEST FOR CANCELLATION OR

SURRENDER OF A DRIVER LICENSE OR
IDENTIFICATION CARD

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

STATE

LICENSE OR ID CARD NUMBER TO BE CANCELLED DATE OF BIRTH

LOCATION OF LICENSE

Lost/destroyed

Attached

ZIP CODE

Other (explain on reverse)

Voluntary surrender or I voluntarily surrender and request the cancellation of my:

Driver License (DL) or
Identification Card (ID)
cancellation of a
Reason for the cancellation or surrender: ________________________________________________
DL or ID Card
Is the license in the minors possession? ....................
Is there a change in the custody of the minor? ............

Yes
Yes

No
No

Person cancelling minor

childs application or I certify under penalty of perjury under the laws of the state of California that:
(check one)
I signed the minors application for a license.
driver license

I did not sign the application but I gave written consent to the issuance of the minors license.
I did not sign the application but now have custody of the minor.

PRINT YOUR NAME

Signature of person
completing the form

SIGNATURE

ADDRESS

DMV Employee

SIGNATURE OF EMPLOYEE AND ID NUMBER

OFFICE NUMBER

DATE

DL 142 (REV 8/93) WWW

CUT ON LINE AND KEEP THIS PART FOR YOUR RECORDS

142

REQUEST FOR CANCELLATION OR

SURRENDER OF A DRIVER LICENSE OR
IDENTIFICATION CARD

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

STATE

LICENSE OR ID CARD NUMBER TO BE CANCELLED DATE OF BIRTH

LOCATION OF LICENSE

Lost/destroyed

Attached

ZIP CODE

Other (explain on reverse)

Voluntary surrender or I voluntarily surrender and request the cancellation of my:

Driver License (DL) or
Identification Card (ID)
cancellation of a
Reason for the cancellation or surrender: ________________________________________________
DL or ID Card
Is the license in the minors possession? ....................
Is there a change in the custody of the minor? ............

Yes
Yes

No
No

Person cancelling minor

childs application or I certify under penalty of perjury under the laws of the state of California that:
(check one)
I signed the minors application for a license.
driver license

I did not sign the application but I gave written consent to the issuance of the minors license.
I did not sign the application but now have custody of the minor.

PRINT YOUR NAME

Signature of person
completing the form

SIGNATURE

ADDRESS

DMV Employee

SIGNATURE OF EMPLOYEE AND ID NUMBER

OFFICE NUMBER

DL 142 (REV 8/93) WWW

Print

Clear Form

DATE