CHANGE OF ADDRESS AND ORGAN/TISSUE DONOR STATUS
B-58 REV. 12-2013
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
On The Web At ct.gov/dmv
INSTRUCTIONS - PLEASE PRINT INFORMATION
OPERATOR'S LICENSE/NON-DRIVER ID MOTOR VEHICLE REGISTRATION
I CONSENT TO ORGAN AND TISSUE DONATION AND WISH TO BE
IN THE DONOR REGISTRY
CHANGE OF ADDRESS IS NOT FOR VOTER REGISTRATION PURPOSES
Joint owners may use this form if both operators' license/non-driver ID numbers are listed.
Form must be signed and dated by all applicants.
Copy information from your current registration. If more than four (4) marker plate numbers, use additional change of
Keep your license/non-driver ID(s) and registration(s). On the registration(s), cross out the old address and write the new
address in the space provided. Affix the new address label to the back of your license/non-driver ID(s). Labels can be
obtained from any Police Department or by calling DMV's Phone Center.
In addition to DMV, PLEASE contact your local post office to change your official mailing address.
NAME (Last, First, Middle Initial) - APPLICANT 1 NAME (Last, First, Middle Initial) - APPLICANT 2
(NEW) MAILING ADDRESS (No. and Street, City or Town, State, Zip Code)
RESIDENT ADDRESS, IF DIFFERENT FROM MAILING ADDRESS
Tax Town - Connecticut town where vehicle in the normal course
of operation most frequently leaves from, returns to or remains.
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, the undersigned, under penalty of false statement, in
accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes. I understand that if I make a statement which I do not
believe to be true with the intent to mislead the commissioner, I will be subject to prosecution under the above-cited laws.
OPERATOR'S LICENSE/NON-DRIVER ID NUMBER(S) (9 digits)
TYPE OF PLATE (Camper, Passenger, Comb., etc) MARKER PLATE NUMBER EXPIRATION DATE
Mail this form to: DMV Data Entry, 60 State Street, Wethersfield CT 06161
I NO LONGER WISH TO BE IN THE DONOR REGISTRY