
142
REQUEST FOR CANCELLATION OR
SURRENDER OF A DRIVER LICENSE OR
IDENTIFICATION CARD
DMV USE ONLY
Doubled From
To
Information about
the document
being cancelled
or surrendered
NAME OF PERSON AS SHOWN ON THE LICENSE OR IDENTIFICATION CARD TO BE CANCELLED
ADDRESS CITY STAT E ZIP CODE
LICENSE OR ID CARD NUMBER TO BE CANCELLED DATE OF BIRTH LOCATION OF LICENSE
Lost/destroyed Attached Other (explain on reverse)
Voluntary surrender
or cancellation of
a DL or ID Card
I voluntarily surrender and request the cancellation of my: Driver License (DL) or Identication Card (ID)
Reason for the cancellation or surrender:
Person cancelling
minor child’s
application or
driver license
Is the license in the minor’s possession?
Is there a change in custody of the minor?
Yes No
Yes No
I certify under penalty of perjury under the laws of the state of California that: (check one)
I signed the minor’s application for a license.
I did not sign the application but I gave written consent to the issuance of the minor’s license.
I did not sign the application but now have custody of the minor.
Signature
of person
completing
the form
PRINT YOUR NAME
SIGNATURE
X
DAT E
ADDRESS
DMV Employee
SIGNATURE OF EMPLOYEE AND ID NUMBER
X
OFFICE NUMBER DAT E
DL 142 (REV. 12/2014) WWW
STATE OF CALIFORNIA
DEPARTMENT OF MOTOR VEHICLES
®
A Public Service Agency
CUT ON LINE AND KEEP THIS PART FOR YOUR RECORDS
142
REQUEST FOR CANCELLATION OR
SURRENDER OF A DRIVER LICENSE OR
IDENTIFICATION CARD
DMV USE ONLY
Doubled From
To
Information about
the document
being cancelled
or surrendered
NAME OF PERSON AS SHOWN ON THE LICENSE OR IDENTIFICATION CARD TO BE CANCELLED
ADDRESS CITY STAT E ZIP CODE
LICENSE OR ID CARD NUMBER TO BE CANCELLED DATE OF BIRTH LOCATION OF LICENSE
Lost/destroyed Attached Other (explain on reverse)
Voluntary surrender
or cancellation of
a DL or ID Card
I voluntarily surrender and request the cancellation of my: Driver License (DL) or Identication Card (ID)
Reason for the cancellation or surrender:
Person cancelling
minor child’s
application or
driver license
Is the license in the minor’s possession?
Is there a change in custody of the minor?
Yes No
Yes No
I certify under penalty of perjury under the laws of the state of California that: (check one)
I signed the minor’s application for a license.
I did not sign the application but I gave written consent to the issuance of the minor’s license.
I did not sign the application but now have custody of the minor.
Signature
of person
completing
the form
PRINT YOUR NAME
SIGNATURE
X
DAT E
ADDRESS
DMV Employee
SIGNATURE OF EMPLOYEE AND ID NUMBER
X
OFFICE NUMBER DAT E
DL 142 (REV. 12/2014) WWW
STATE OF CALIFORNIA
DEPARTMENT OF MOTOR VEHICLES
®
A Public Service Agency