Fillable Printable Dl Parental Consent Withdrawal

Dl Parental Consent Withdrawal

Withdrawal/ReinstatementofParentalConsent

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)

PS33061B-01 (07/16)

A Withdrawal of Parental Consent

I am requesting that Driver and Vehicle Services cancel the driving privileges of the

above-named child, who is under age 18.

B Reinstatement

I request that the driving privileges of the above-named child, who is under age 18, be

reinstated. I understand that he or she may not operate a motor vehicle until receiving

written notification from Driver and Vehicle Services that driving privileges have been

reinstated.

I have read and fully understand the procedures for canceling and reinstating the above-named child's

driving privileges. I have informed him/her that s/he may not operate a motor vehicle until receiving written

notification from Driver and Vehicle Services that his/her driving privileges have been reinstated.

I also state that I am the parent/guardian who signed the application originally granting consent to drive, or

who signed the Withdrawal of Parental Consent/Voluntary Surrender form canceling the driving privileges

of the above-named minor child.

Parent/guardian signature of above-named minor child

Date (mm/dd/yy)

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