Voluntary Surrender of Driving Privileges
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
The form can be mailed or submitted in person to Driver and Vehicle Services, 445 Minnesota St. -
Suite 170, St. Paul, Minnesota 55101-5170. It may also be faxed to 651-797-1760
• If you have questions or need additional information, please contact DVS at 651-296-2025 or
651-282-6555 (TTY).
• To ensure that this request is processed in a timely manner, please type or print legibly.
Name (LAST, FIRST, MIDDLE INITIAL)
Date of Birth (mm/dd/yy)
DL Number (OMIT DASHES)
PS33061A-01 (07/16)
A Voluntary Surrender
I am over age 18 and voluntarily request cancellation of my driving privileges. I have read and
fully understand the procedures for voluntarily cancelling my driving privileges
I will not operate a motor vehicle again until I request and receive written notification from
Driver and Vehicle Services that my driving privileges have been reinstated.
B Reinstatement
I am over age 18 and request that my driving privileges be reinstated. I understand that
I may not operate a motor vehicle until I receive written notification from Driver and
Vehicle Services that my driving privileges have been reinstated.
I have read and fully understand the procedures for voluntarily canceling and reinstating my driving
privileges. I will not operate a motor vehicle again until I receive written notification from Driver and
Vehicle Services that my driving privileges have been reinstated.
Signature of License Holder Over Age 18
Date (mm/dd/yy)
