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14 2m Wis. Stats. MV3592 9/2012 Clear Form STATEMENT OF PURPOSE/EFFECT Under Wisconsin law the Department of Transportation Division of Motor Vehicles is required to provide information from its records to requesters. REQUEST TO WITHHOLD NAME AND ADDRESS Wisconsin Department of Transportation s. 341. 08 1m 342. 06 1 i 343. This information may be used for marketing purposes. If you do not want your name and address included in requests for 10 or more records complete and return this form* This form will not eliminate mailings that originate from other sources of information used by marketers. Certain requesters are authorized by law to receive your name and address upon request provided such information is used for the purpose of writing and renewing insurance policies and related underwriting billing and paying of insurance claims vehicle safety recall notification programs and law enforcement activities. A request to withhold name and address is limited to individuals. If a vehicle is jointly owned only the owner making the request is affected* Once a request is processed the designation will remain in effect until the person asks the department to remove it. Mail completed form to PO Box 7983 Madison WI 53707-7983 If you have additional questions please write to the above address or call 608 266-1466 for vehicle registration information or 608 266-2353 for driver license information* Instructions To request withholding of your name and address from driver license vehicle registration or identification cards for the physically disabled records please provide the following information* Use of this form is limited to one person* Please print legibly. Provide COMPLETE information* The following information is REQUIRED. Name Last First MI As Shown on Driver License or Vehicle Record Birth Date m/d/yyyy Residence Street Address City State and ZIP Code Driver License Number if applicable Incomplete or illegible forms will not be processed* X Signature Date m/d/yyyy Please check ALL that apply. I have moved* Please record my new residence address as shown above. I do not want my name and address provided from the Wisconsin Department of Transportation Driver or Vehicle records. I previously requested withholding of my name and address but want to reverse that designation* Print. This information may be used for marketing purposes. If you do not want your name and address included in requests for 10 or more records complete and return this form* This form will not eliminate mailings that originate from other sources of information used by marketers. Certain requesters are authorized by law to receive your name and address upon request provided such information is used for the purpose of writing and renewing insurance policies and related underwriting billing and paying of insurance claims vehicle safety recall notification programs and law enforcement activities. Certain requesters are authorized by law to receive your name and address upon request provided such information is used for the purpose of writing and renewing insurance policies and related underwriting billing and paying of insurance claims vehicle safety recall notification programs and law enforcement activities. A request to withhold name and address is limited to individuals. If a vehicle is jointly owned only the owner making the request is affected* Once a request is processed the designation will remain in effect until the person asks the department to remove it.

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