Form CI-1 Request to Renew or Obtain Duplicate Driver License/Identification Card by Mail Due to Medical Conditions - Connecticut

Form CI-1 is a Connecticut Department of Motor Vehicles form also known as the "Request To Renew Or Obtain Duplicate Driver License/identification Card By Mail Due To Medical Conditions". The latest edition of the form was released in April 1, 2018 and is available for digital filing.

Download an up-to-date Form CI-1 in PDF-format down below or look it up on the Connecticut Department of Motor Vehicles Forms website.

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REQUEST TO RENEW OR OBTAIN DUPLICATE
DRIVER LICENSE/IDENTIFICATION CARD BY MAIL
DUE TO MEDICAL CONDITIONS
CI-1 Rev. 4-18
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
CENTRALIZED ISSUANCE OPERATIONS UNIT
60 STATE STREET, WETHERSFIELD, CT 06161-0001
On the Web at: ct.gov/dmv
Telephone: (860)263-5148
Fax: (860)263-5591
INSTRUCTIONS:
1.
PART A must be completed by applicant.
2.
PART B must be completed by a licensed physician. The applicant must return this form by mail to the address above.
This form must be submitted with the Request for a Connecticut Driver's License/Identification Card by Mail (B-350).
3.
Physicians (IMPORTANT): If the applicant’s medical condition is a chronic health problem which in your judgment will significantly
affect his or her ability to safely operate a motor vehicle, or the applicant has recurrent periods of unconsciousness uncontrolled by
medical treatment, and the applicant is attempting to RENEW or OBTAIN A DUPLICATE OF HIS or HER DRIVER LICENSE do not
use this form.
Connecticut General Statutes Section 14-46 allows any physician to report to the Department of Motor Vehicles in writing the name,
age and address of any person diagnosed to have a chronic health problem which in such physician’s judgment will significantly affect
the applicant’s ability to safely operate a motor vehicle. The Department of Motor Vehicles will accept notification by:
a letter from the physician on his or her business letterhead stating the applicant can no longer safely operate a motor vehicle due
a.
to their health problem
b.
Affidavit to Report a Driver Who May be Unable to Safely Operate a Motor Vehicle (P244). This form must be notarized and may
be downloaded at: http://www.ct.gov/dmv
If you are unable to appear in person to obtain a duplicate or renew your Connecticut driver's license/identification card due to a medical condition the
information below must be provided to the DMV and certified by a licensed physician. NOTE: If you are no longer a resident of the State of Connecticut your
Connecticut driver's license/identification card must be turned in and a new license/identification card must be applied for in the state in which you currently
reside.
PART A - COMPLETED BY APPLICANT
NAME OF PERSON WHO IS REQUESTING TO RENEW LICENSE/ID BY MAIL
DATE OF BIRTH
DRIVER'S LICENSE/IDENTIFICATION CARD NUMBER (If Known)
ADDRESS
DAYTIME TELEPHONE NUMBER
E-MAIL ADDRESS
APPLICANT: MAY WE CONTACT YOU VIA E-MAIL REGARDING YOUR REQUEST, IF NECESSARY?
YES
NO
I swear or affirm under penalty of false statement in accordance with the provision of section 14-110 and 53a-157b of the Connecticut General Statutes, that I
am unable to appear in person at this time to renew my Connecticut driver license/identification card due to my current medical condition. 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.
APPLICANT SIGNATURE
DATE SIGNED
X
PART B - COMPLETED BY PHYSICIAN
Physicians: By completing and signing the section below, you are certifying under penalty of false statement that the above applicant is currently and
temporarily unable to physically appear at an authorized DMV office/location to renew their license in person due to a medical condition.
PHYSICIAN'S NAME
MEDICAL LICENSE NUMBER
LICENSING STATE
OFFICE ADDRESS
OFFICE TELEPHONE NUMBER
OFFICE E-MAIL
PHYSICIAN: MAY WE CONTACT YOU VIA E-MAIL TO VERIFY YOUR SIGNATURE?
CONDITION IS TEMPORARY
IF YES, ESTIMATE DATE OF RECOVERY
YES
NO
YES
NO
I swear and affirm under penalty of false statement in accordance with the provisions of section 14-110 and 53a-157b of the Connecticut General Statutes
that the applicant listed above is currently under my care and is medically unable to appear in person to renew his/her license at this time. 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 cited-laws.
SIGNATURE OF PHYSICIAN
DATE SIGNED
X
REQUEST TO RENEW OR OBTAIN DUPLICATE
DRIVER LICENSE/IDENTIFICATION CARD BY MAIL
DUE TO MEDICAL CONDITIONS
CI-1 Rev. 4-18
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
CENTRALIZED ISSUANCE OPERATIONS UNIT
60 STATE STREET, WETHERSFIELD, CT 06161-0001
On the Web at: ct.gov/dmv
Telephone: (860)263-5148
Fax: (860)263-5591
INSTRUCTIONS:
1.
PART A must be completed by applicant.
2.
PART B must be completed by a licensed physician. The applicant must return this form by mail to the address above.
This form must be submitted with the Request for a Connecticut Driver's License/Identification Card by Mail (B-350).
3.
Physicians (IMPORTANT): If the applicant’s medical condition is a chronic health problem which in your judgment will significantly
affect his or her ability to safely operate a motor vehicle, or the applicant has recurrent periods of unconsciousness uncontrolled by
medical treatment, and the applicant is attempting to RENEW or OBTAIN A DUPLICATE OF HIS or HER DRIVER LICENSE do not
use this form.
Connecticut General Statutes Section 14-46 allows any physician to report to the Department of Motor Vehicles in writing the name,
age and address of any person diagnosed to have a chronic health problem which in such physician’s judgment will significantly affect
the applicant’s ability to safely operate a motor vehicle. The Department of Motor Vehicles will accept notification by:
a letter from the physician on his or her business letterhead stating the applicant can no longer safely operate a motor vehicle due
a.
to their health problem
b.
Affidavit to Report a Driver Who May be Unable to Safely Operate a Motor Vehicle (P244). This form must be notarized and may
be downloaded at: http://www.ct.gov/dmv
If you are unable to appear in person to obtain a duplicate or renew your Connecticut driver's license/identification card due to a medical condition the
information below must be provided to the DMV and certified by a licensed physician. NOTE: If you are no longer a resident of the State of Connecticut your
Connecticut driver's license/identification card must be turned in and a new license/identification card must be applied for in the state in which you currently
reside.
PART A - COMPLETED BY APPLICANT
NAME OF PERSON WHO IS REQUESTING TO RENEW LICENSE/ID BY MAIL
DATE OF BIRTH
DRIVER'S LICENSE/IDENTIFICATION CARD NUMBER (If Known)
ADDRESS
DAYTIME TELEPHONE NUMBER
E-MAIL ADDRESS
APPLICANT: MAY WE CONTACT YOU VIA E-MAIL REGARDING YOUR REQUEST, IF NECESSARY?
YES
NO
I swear or affirm under penalty of false statement in accordance with the provision of section 14-110 and 53a-157b of the Connecticut General Statutes, that I
am unable to appear in person at this time to renew my Connecticut driver license/identification card due to my current medical condition. 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.
APPLICANT SIGNATURE
DATE SIGNED
X
PART B - COMPLETED BY PHYSICIAN
Physicians: By completing and signing the section below, you are certifying under penalty of false statement that the above applicant is currently and
temporarily unable to physically appear at an authorized DMV office/location to renew their license in person due to a medical condition.
PHYSICIAN'S NAME
MEDICAL LICENSE NUMBER
LICENSING STATE
OFFICE ADDRESS
OFFICE TELEPHONE NUMBER
OFFICE E-MAIL
PHYSICIAN: MAY WE CONTACT YOU VIA E-MAIL TO VERIFY YOUR SIGNATURE?
CONDITION IS TEMPORARY
IF YES, ESTIMATE DATE OF RECOVERY
YES
NO
YES
NO
I swear and affirm under penalty of false statement in accordance with the provisions of section 14-110 and 53a-157b of the Connecticut General Statutes
that the applicant listed above is currently under my care and is medically unable to appear in person to renew his/her license at this time. 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 cited-laws.
SIGNATURE OF PHYSICIAN
DATE SIGNED
X

Download Form CI-1 Request to Renew or Obtain Duplicate Driver License/Identification Card by Mail Due to Medical Conditions - Connecticut

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