Form E-224 "Application for Withholding of Resident Address" - Connecticut

What Is Form E-224?

This is a legal form that was released by the Connecticut Department of Motor Vehicles - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest edition provided by the Connecticut Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form E-224 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form E-224 "Application for Withholding of Resident Address" - Connecticut

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APPLICATION FOR WITHHOLDING
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
OF RESIDENT ADDRESS
REGISTRATION BUSINESS PROCESSING UNIT
E-224 REV. 12-2017
On the web at: ct.gov/dmv
INSTRUCTIONS (NEW/CHANGE):
Complete this application and submit with a photocopy of your credential demonstrating your official status (example: copy of employee ID) and email or mail to address below.
1.
You may only withhold home address on your license and on any vehicle/vessel you are the registered owner. Your business address will appear on license and DMV record.
2.
DMV will email you a confirmation at your PERSONAL email when the change is made to your record. Make email legible.
3.
DMV customer records such as address are protected from FOIA disclosure. This application is only for persons whose law enforcement related work makes them eligible to
use a business address on their driver license under CGS 14-10(e).
INSTRUCTIONS (NO LONGER QUALIFY):
1.
Complete this application with the exception of the "Supervisor's Certification". Email or mail to the address below.
2.
DMV will email you a confirmation at your PERSONAL email when the change is made to your record. Make email legible.
MAIL TO: Centralized Issuance Unit/CA Unit, Department of Motor Vehicles, 60 State Street, Wethersfield, CT 06161-5001 OR EMAIL TO: DMV.CIU@ct.gov
NEW
CHANGE
NO LONGER QUALIFY
TYPE OF
IF APPLICATION CHANGE, SPECIFY THE NATURE OF THE CHANGE
APPLICATION
NAME OF BUSINESS ORGANIZATION OR DEPARTMENT
APPLICANT'S DATE OF BIRTH
NAME OF APPLICANT
BUSINESS TELEPHONE NO.
BUSINESS ADDRESS
(Number and Street)
APPLICANT'S OFFICIAL TITLE
(City or Town)
(State)
(Zip Code)
APPLICANT'S HOME PHONE NUMBER
RESIDENT ADDRESS (Confidential)
Number and Street
City or Town
State
Zip Code
BUSINESS E-MAIL ADDRESS
PERSONAL E-MAIL ADDRESS
Check here if this change of residence address is NOT for voter registration purposes
IF THIS IS A NEW
If you are already a registered voter and you do not check this box, your address will be changed in your voter record as follows:
RESIDENCE ADDRESS:
(1) If your new residence address is in the same city/town, your address will be updated with the registrar in your city/town; or
APPLICANT
(2) if your new residence address is in a different city/town, this form will be used for voter registration in your new city/town.
INFORMATION
OFFICIAL STATUS OF APPLICANT (You must check one below to qualify)
Federal Court Judge
Federal Court Magistrate
Judge of the Superior, Appellate or Supreme Court of Connecticut
Police Officer as defined in section 7-294
Agency Name
Member of State Police, Department of Emergency Services & Public Protection
Department of Corrections Employee
Attorney who represents or has represented the state in criminal prosecution
Member or Employee of Board of Pardons and Parole
Judicial branch employee regularly engaged in court ordered enforcement or investigation activities. (e.g. Adult /Juvenile Probation Officer,
Support Enforcement Officer, Family Relations Counselor, Victim Service Advocate)
Inspector employed by the Division of Criminal Justice
State Referee, as defined in Section 52-434 C.G.S.
Federal law enforcement officer who works and resides in Connecticut.
Lake Patrolman appointed pursuant to subsection (a) of Section 7-151(b) engaged in boating law enforcement
I certify, under penalty of false statement, that the above applicant qualifies for Withholding of Resident Address on DMV records per Section 14-10(e) of the Connecticut General
Statutes and the applicant requires the added protection of such withholding as a direct result of the applicant's job duties. The information provided to the Commissioner of Motor
Vehicles herein, is subscribed by me, the undersigned, under penalty of false statement, in accordance with provisions of Section 14-110 and 53a-157b of the Connecticut General
Statutes. I understand 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.
SUPERVISOR'S
NAME OF APPLICANT'S SUPERVISOR (Please print clearly)
TITLE OF SUPERVISOR
CERTIFICATION
SIGNATURE OF APPLICANT'S SUPERVISOR
DATE SIGNED
SUPERVISOR'S PHONE NO.
X
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
REGISTRATION(S)
IN NAME OF
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
APPLICANT
(Do NOT include
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
VESSEL REGISTRATION NUMBER
leased vehicles)
I certify under penalty of false statement that the information furnished is true and accurate. I hereby request under subsection (e) of Section 14-10 of the Connecticut General Statutes that my resident address as
given above be withheld from public inspection on all DMV records pertaining to my Connecticut operator's license and/or registration(s) specified. I will submit another application, if the information specified above
changes, or if I no longer qualify for withholding of my resident address due to change in official status. The information provided to the Commissioner of Motor Vehicles herein, is subscribed by me, the undersigned,
under penalty of false statement, in accordance with provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes. I understand 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.
APPLICANT'S SIGNATURE
CT OPERATOR LICENSE NO.
EMPLOYEE OR BADGE NO.
DATE SIGNED
X
REVIEWED BY:
DATE OP KEYED/KEYIST'S INITIALS
DATE REG KEYED/KEYIST'S INITIALS
DMV USE
NOT APPROVED
APPROVED
ONLY
APPLICATION FOR WITHHOLDING
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
OF RESIDENT ADDRESS
REGISTRATION BUSINESS PROCESSING UNIT
E-224 REV. 12-2017
On the web at: ct.gov/dmv
INSTRUCTIONS (NEW/CHANGE):
Complete this application and submit with a photocopy of your credential demonstrating your official status (example: copy of employee ID) and email or mail to address below.
1.
You may only withhold home address on your license and on any vehicle/vessel you are the registered owner. Your business address will appear on license and DMV record.
2.
DMV will email you a confirmation at your PERSONAL email when the change is made to your record. Make email legible.
3.
DMV customer records such as address are protected from FOIA disclosure. This application is only for persons whose law enforcement related work makes them eligible to
use a business address on their driver license under CGS 14-10(e).
INSTRUCTIONS (NO LONGER QUALIFY):
1.
Complete this application with the exception of the "Supervisor's Certification". Email or mail to the address below.
2.
DMV will email you a confirmation at your PERSONAL email when the change is made to your record. Make email legible.
MAIL TO: Centralized Issuance Unit/CA Unit, Department of Motor Vehicles, 60 State Street, Wethersfield, CT 06161-5001 OR EMAIL TO: DMV.CIU@ct.gov
NEW
CHANGE
NO LONGER QUALIFY
TYPE OF
IF APPLICATION CHANGE, SPECIFY THE NATURE OF THE CHANGE
APPLICATION
NAME OF BUSINESS ORGANIZATION OR DEPARTMENT
APPLICANT'S DATE OF BIRTH
NAME OF APPLICANT
BUSINESS TELEPHONE NO.
BUSINESS ADDRESS
(Number and Street)
APPLICANT'S OFFICIAL TITLE
(City or Town)
(State)
(Zip Code)
APPLICANT'S HOME PHONE NUMBER
RESIDENT ADDRESS (Confidential)
Number and Street
City or Town
State
Zip Code
BUSINESS E-MAIL ADDRESS
PERSONAL E-MAIL ADDRESS
Check here if this change of residence address is NOT for voter registration purposes
IF THIS IS A NEW
If you are already a registered voter and you do not check this box, your address will be changed in your voter record as follows:
RESIDENCE ADDRESS:
(1) If your new residence address is in the same city/town, your address will be updated with the registrar in your city/town; or
APPLICANT
(2) if your new residence address is in a different city/town, this form will be used for voter registration in your new city/town.
INFORMATION
OFFICIAL STATUS OF APPLICANT (You must check one below to qualify)
Federal Court Judge
Federal Court Magistrate
Judge of the Superior, Appellate or Supreme Court of Connecticut
Police Officer as defined in section 7-294
Agency Name
Member of State Police, Department of Emergency Services & Public Protection
Department of Corrections Employee
Attorney who represents or has represented the state in criminal prosecution
Member or Employee of Board of Pardons and Parole
Judicial branch employee regularly engaged in court ordered enforcement or investigation activities. (e.g. Adult /Juvenile Probation Officer,
Support Enforcement Officer, Family Relations Counselor, Victim Service Advocate)
Inspector employed by the Division of Criminal Justice
State Referee, as defined in Section 52-434 C.G.S.
Federal law enforcement officer who works and resides in Connecticut.
Lake Patrolman appointed pursuant to subsection (a) of Section 7-151(b) engaged in boating law enforcement
I certify, under penalty of false statement, that the above applicant qualifies for Withholding of Resident Address on DMV records per Section 14-10(e) of the Connecticut General
Statutes and the applicant requires the added protection of such withholding as a direct result of the applicant's job duties. The information provided to the Commissioner of Motor
Vehicles herein, is subscribed by me, the undersigned, under penalty of false statement, in accordance with provisions of Section 14-110 and 53a-157b of the Connecticut General
Statutes. I understand 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.
SUPERVISOR'S
NAME OF APPLICANT'S SUPERVISOR (Please print clearly)
TITLE OF SUPERVISOR
CERTIFICATION
SIGNATURE OF APPLICANT'S SUPERVISOR
DATE SIGNED
SUPERVISOR'S PHONE NO.
X
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
REGISTRATION(S)
IN NAME OF
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
APPLICANT
(Do NOT include
REGISTRATION PLATE NUMBER
REGISTRATION CLASS
VESSEL REGISTRATION NUMBER
leased vehicles)
I certify under penalty of false statement that the information furnished is true and accurate. I hereby request under subsection (e) of Section 14-10 of the Connecticut General Statutes that my resident address as
given above be withheld from public inspection on all DMV records pertaining to my Connecticut operator's license and/or registration(s) specified. I will submit another application, if the information specified above
changes, or if I no longer qualify for withholding of my resident address due to change in official status. The information provided to the Commissioner of Motor Vehicles herein, is subscribed by me, the undersigned,
under penalty of false statement, in accordance with provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes. I understand 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.
APPLICANT'S SIGNATURE
CT OPERATOR LICENSE NO.
EMPLOYEE OR BADGE NO.
DATE SIGNED
X
REVIEWED BY:
DATE OP KEYED/KEYIST'S INITIALS
DATE REG KEYED/KEYIST'S INITIALS
DMV USE
NOT APPROVED
APPROVED
ONLY