CA DMV DL 410 FO Form 2024 - Fill, Sign Online, Download & Print - No Signup
704
CALIFORNIA DRIVER LICENSE
RENEWAL BY MAIL ELIGIBILITY INFORMATION
INSTRUCTIONS
(Please use Blue or Black ink.)
In order to complete your renewal by mail you must provide your Social Security Number.
•
If you answer YES to any of the questions below, STOP and make an appointment to visit your local DMV office to renew in person.
•
If you answer “No” to all questions below, please complete the attached form.
ARE YOU ELIGIBLE TO RENEW BY MAIL?
• Have your last two licenses been renewed by mail?
• Has your license been expired for more than one year?
• Does your license expire more than 120 days from today?
• Are you currently on any type of driving probation?
• Are you changing/correcting your name?
• Do you have a driver license from more than one state or jurisdiction?
WITHIN THE PAST TWO YEARS:
• Were you convicted of any Vehicle Code moving violations?
• Did you fail to appear in court for any Vehicle Code moving violation?
• Were you suspended for driving under the influence, or for refusing, or failing to complete
a chemical or preliminary alcohol screening (PAS) test?
• Have you been at fault in one or more collisions, as reported by law enforcement?
DISCLOSURES
MEDICAL INFORMATION
The following conditions that may affect your ability to operate a motor vehicle safely include, but are not limited to: loss of consciousness; episode of marked confusion caused by any
condition which may bring about recurring lapses; disease, disorder, or disability (examples of these are epilepsy, diabetes, stroke, cataracts, Parkinson’s disease); decrease or change in
your vision due to cataracts, macular degeneration, diabetic retinopathy, glaucoma, retinitis pigmentosa, or other progressive condition; health problems because of alcohol or drug abuse.
VETERAN STATEMENT
By marking the veteran box on this application, I certify that I am a veteran of the United States Armed Forces and that I want to receive veteran benefits information from the California
Department of Veterans Affairs (CalVet). By marking the veteran box on this application, I also consent to DMV transmitting my name and mailing address to CalVet for this purpose only,
and I certify that I have been notified that this transmittal will occur.
ORGAN & TISSUE DONOR STATEMENT
By registering as an organ and tissue donor, you agree to the recovery of organs and tissues after your death. Your decision does not need approval from anyone. If you are under 18 years
old, you can register, and your parents or legal guardian will make the final donation decision. You may contact Donate Life California at
www.donateLIFEcalifornia.org
or (866) 797-2366
to get more information about donation and to:
•
Add or remove your name from the registry
•
Limit your donation to specific organs or tissues (e.g. lungs, kidney, heart)
•
Decide how your organ and tissue donation will be used (e.g. transplants or research)
You agree that the DMV can electronically send your full name, home or mailing address, year of birth, and California driver license or identification card number to Donate Life California.
VOTER REGISTRATION
•
If sharing your address could put you in life-threatening danger, you may be eligible to register to vote confidentially. For more information, contact the
Safe at Home
program
at (877) 322-5227 or visit
www.sos.ca.gov/safeathome/
.
•
For U.S. citizens only
. If you indicate that you are eligible to vote, the DMV will send all of the voter registration information collected on this form, including your digital signature,
to the Secretary of State. The office where you registered will remain confidential and will be used only for voter registration purposes.
•
If you are eligible to vote and decline to register to vote,
your decision will remain confidential;
however this information will be sent to the Secretary of State to be used only for
voter outreach and registration purposes.
•
Voter registration information provided on this application is confidential. The DMV does not make voter eligibility determinations.
•
If you have not received voter registration information within four weeks
of registering,
contact your county elections official or the Secretary of State.
•
Please visit
voterstatus.sos.ca.gov/
for more information about your voter registration or
www.sos.ca.gov
for general information.
CRIMINAL PROSECUTION
•
If you submit fraudulent information, the DMV may pursue criminal prosecution.
•
Any person who uses false documents to conceal their true citizenship or resident alien status is guilty of a felony pursuant to
California Penal Code
§114.
FINANCIAL RESPONSIBILITY
•
Financial responsibility (commonly known as insurance) is required on all vehicles operated or parked on California roadways. You must carry evidence of financial responsibility
in your vehicle at all times and it must be provided when: requested by law enforcement, renewing vehicle registration, the vehicle is involved in a traffic collision.
•
If you cannot afford liability insurance, you may be eligible for the California Low Cost Automobile Insurance Program. Additional information is available at
www.mylowcostauto.com
or by calling (866) 602-8861.
PAYMENTS / REFUNDS
•
Visit
dmv.ca.gov
to review payment options at your local DMV field office. If you are mailing your renewal, payment must be by check. (Checks should be payable to DMV).
•
Once this application form and fee have been submitted, no refunds will be made.
PRIVACY NOTICE ON COLLECTION
•
DMV collection of personal information is governed by:
California Information Practices Act
,
Civil Code
§1798 et seq;
Government Code
(GC) §11015.5;
California Public Records Act
GC §6250 et seq.;
California Vehicle Code
(CVC) §1808;
Driver’s Privacy Protection Act
(18
United States Code
§§2721-2725).
•
The information collected may be shared with authorized service providers, state, federal, and/or local government agencies, law enforcement, and commercial entities as authorized
by law that support the driver’s license or identification card programs.
•
All information on this form is mandatory except where noted.
•
DMV uses this information to determine your eligibility for a driver’s license or identification card and for the administration of driver’s license laws.
•
DMV may deny your application for not providing the required information. Failure to provide the information required on this form is cause for refusal to issue a driver’s license or
identification card, or, in some cases, cancellation or withdrawal of the driving privilege.
•
You have the right to review and request corrections/deletions of DMV maintained records containing your personal information. Please visit
dmv.ca.gov
for more information on
the
Information Practices Act
.
•
Questions about this form should be directed to: Department of Motor Vehicles, Driver License Inquiries, PO Box 942890, Sacramento, CA 94290.
•
For privacy policy questions or requests contact us at: DMV Chief Privacy Officer, 2415 First Avenue, MS F127, Sacramento, CA 95818 or (916) 657-6340.
CERTIFICATIONS
•
I agree to submit to a chemical test of my blood, breath, or urine for the purpose of determining the alcohol or drug content of my blood when testing is requested by a peace
officer acting in accordance with
California Vehicle Code
(CVC) §23612.
•
I am hereby advised that being under the influence of alcohol or drugs, or both, impairs the ability to safely operate a motor vehicle. Therefore, it is extremely dangerous to human life to
drive while under the influence of alcohol or drugs, or both. If I drive while under the influence of alcohol or drugs, or both, and as a result, a person is killed, I can be charged with murder.
•
By signing this application, I certify that I was notified that if I am under 21 years of age, I cannot legally drive with a blood alcohol concentration (BAC) of 0.01% or more. Driving
with a BAC of 0.01% or more, or refusing to take, or failing to complete an alcohol screening or drug test, results in a one-year suspension of my driving privilege.
•
By signing this application, I certify that I was notified that if I am currently on court probation for a driving under the influence offense, I cannot legally drive with a BAC of 0.01%
or more. Driving with a BAC of 0.01% or more results in a one-year suspension of my driving privilege. Refusing to take, or failing to complete an alcohol screening or chemical
test will result in a two to three year suspension/revocation of my driving privilege.
•
I am the person whose name appears on the front of this form. The mailing address shown is valid, existing, and accurate. I agree to accept service of process at this mailing
address according to §§415.20(b), 415.30(a), and 416.90 of the
California Code of Civil Procedure
.
•
I understand DMV may add traffic convictions reported by other states or jurisdictions to my driving record that may result in sanctions against my California driving privilege.
•
By signing this form, I am acknowledging my presence in the United States is authorized under federal law, except as specified in CVC §12801.
•
I understand I may have no more than one driver license in my possession or under my control in accordance with CVC §12511.
•
By signing this application, I certify that I understand traffic signs and signals in accordance with CVC §12800(h).
Page 1 of 3
DL 410 FO (REV. 7/2024)
WWW
*DL410FOINS*
Clear Form
704
CALIFORNIA DRIVER LICENSE
RENEWAL BY MAIL ELIGIBILITY INFORMATION
SECTION 1 — PLEASE TELL US ABOUT YOURSELF
(Use your true full name.)
(Please use Blue or Black ink.)
0
DRIVER LICENSE OR ID CARD NUMBER
STATE OR COUNTRY
EXPIRATION DATE
M M
/
D D
/
Y
Y
Y
Y
LAST NAME
BIRTH DATE
M M
/
D D
/
Y
Y
Y
Y
FIRST NAME
MIDDLE NAME
SUFFIX
(JR., SR., III)
RESIDENTIAL STREET
(WHERE YOU LIVE)
NUMBER, STREET NAME
(ST., AVE., RD., BLVD., ETC.)
CITY
STATE
ZIP CODE
MAILING ADDRESS
(IF DIFFERENT)
NUMBER, STREET NAME
(ST., AVE., RD., BLVD., ETC.)
OR P.O. BOX NUMBER
CITY
STATE
ZIP CODE
MY SOCIAL SECURITY NUMBER IS:
—
—
SECTION 2 — VOTER CHANGE OF ADDRESS
Your voting address will be updated unless you check the box below.
Check this box if you do not want your new address used for voter registration purposes.
SECTION 3 — MEDICAL CONDITIONS
Have you had any medical conditions in the last three (3) years affecting your ability to drive?
(See medical information on page 1 before responding.) .........................................................................
Yes
No
IF YES, PLEASE EXPLAIN
SECTION 4 — VETERANS STATEMENT
(Receiving veteran benefit information is voluntary.)
I have served in the United States Military and would like to receive benefits information for which
I may be eligible from the Department of Veterans Affairs. .......................................................................
Yes
No
SECTION 5 — ORGAN AND TISSUE DONATION
(Organ and tissue donation is voluntary.)
Would you like to register?
Yes, you will be kept on or added to the Donate Life California Donor Registry. A pink “donor” dot will be on your driver’s
license or ID card. This is your decision and cannot be changed by anyone else.
Not at this time. You will not be added to the registry. Your family will make a decision for you after you pass. DMV
can remove the pink dot from your DL/ID card but cannot remove you from the registry. You must contact Donate Life
California (see Disclosures page) to remove your name from the registry.
Would you like to make a financial donation to Donate Life California?
$10
$5
$2
Other
No
One person can save up to 8 lives, and heal over 75 lives through organ and tissue donation for transplantation. You can
register regardless of age or health. Organ donation happens after death, and your decision will not impact medical treatment.
IMPORTANT: CONTINUE TO NEXT PAGE.
WE CANNOT PROCESS YOUR RENEWAL WITHOUT PAGES 2 & 3.
Page 2 of 3
*DL410FO2*
DL 410 FO (REV. 7/2024)
WWW
Clear Form
704
If you are enrolled in a confidential address program, such as Safe At Home, skip to Section 8.
SECTION 6 — VOTER REGISTRATION—
FOR U.S. CITIZENS ONLY.
It is a crime to intentionally provide incorrect information on a voter registration form.
(State law requires eligible citizens be automatically registered to vote, unless they choose not to in this section.)
6a. Are you a United States citizen?
.....................................................................................................
Yes
No
If you answered “No,” you cannot register to vote.
Skip to Section 8.
Voter Registration Requirements
If you answered “YES” to all of the voter registration requirements listed below, you can register to vote:
•
I am a United States citizen
•
My residence address is in California
•
I am at least 18 years old
•
I am not currently serving a state or federal prison term for the conviction of a felony
•
I am not currently found mentally incompetent to vote by a court
6b. Do you meet ALL of the voter registration requirements listed above?
....................................
Yes
No
•
If you answered “No,” you
cannot
register to vote.
Skip to Section 8
.
•
If you answered “Yes” to the above questions, you will be registered to vote. You can choose not to
register by checking the box below.
6c.
I am eligible, but I do
not
want to register to vote or update my voter registration information.
Skip to Section 8
.
•
Do not check this box if you want to register to vote or update your voter registration information.
Continue to Section 7
.
SECTION 7 — VOTER PREFERENCES—
FOR U.S. CITIZENS ONLY.
(To choose or update any voter preferences, you must first indicate you are eligible to vote in Section 6 above.)
Do you want to select or change a political party preference? (Select only one.)
No party. I do not want to choose a
political party preference.
If you select “No Party,” you may not be able
to vote for some parties’ candidate(s) at a
primary election for U.S. President or party
committee.
American Independent Party
Democratic Party
Green Party
Libertarian Party
Peace and Freedom Party
Republican Party
Other:
Vote-by-Mail in All Elections
All active registered voters will be mailed a vote-by-mail ballot for every election. If you want to vote in person, you must turn
in your vote-by-mail ballot or you may be required to vote a provisional ballot.
In what language would you like to receive election materials?
(Select only one.)
English
Spanish
Chinese
Korean
Tagalog
Hindi
Thai
Japanese
Khmer
Vietnamese
Contact Information for voter registration.
(Optional)
Telephone Number: (EXAMPLE: 916-555-1212)
I want to remove my telephone number.
Email address: (EXAMPLE: john.doe@company.com)
I want to remove my email address.
If you do not receive a voter notification card within four weeks, contact your county elections official.
You can also check your voter registration status at
https://voterstatus.sos.ca.gov/.
SECTION 8 — SIGNATURE/PERJURY STATEMENT
I have read, understand and agree with the certifications on this document.
I certify (or declare) under penalty of
perjury under the laws of the State of California that the information I provided is true and correct.
SIGNATURE
X
DATE
EMAIL ADDRESS
(OPTIONAL)
SECTION 9 — WHERE TO MAIL
The renewal fee for basic driver license is $45.00. If you marked the box to make a $2 voluntary contribution to support and
promote the Donate Life California organ and tissue donor registry, include the $2 voluntary contribution with your check or
money order made payable to DMV and mail this form to:
DMV, Attn: Renewal by Mail Unit, PO Box 942890, MS G204,
Sacramento, CA 94290-0001
(Please write your driver license number on the back of your payment document.)
Page 3 of 3
DL 410 FO (REV. 7/2024)
WWW
*DL410FOEND*
Clear Form
