Official Connecticut B 58 Template in PDF
Structure
The Connecticut B 58 form serves multiple purposes related to updating personal information with the Department of Motor Vehicles (DMV). Primarily, it is used for changing an individual's address, whether for an operator's license, non-driver ID, or vehicle registration. The form also addresses the status of organ and tissue donation, allowing individuals to express their consent or withdrawal from the donor registry. To complete the B 58 form, applicants must provide their names, current and new addresses, and relevant identification numbers. It’s important to note that joint owners can utilize the form if both parties' identification numbers are included. Additionally, the form requires signatures from all applicants, ensuring that the information is verified and accurate. After filling out the form, applicants must also inform their local post office of their address change. The B 58 form does not serve as a means for voter registration updates, which is a separate process. Proper completion and submission of this form help maintain accurate records with the DMV and ensure that individuals' preferences regarding organ donation are respected.
Connecticut B 58 Example
If you provide an e-mail address, your registration
renewal notices will only be sent to your e-mail.
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
B-58 IND Rev. 10-2019
FOR DMV INTERNAL USE ONLY
LICENSE/ID CHANGES COMPLETED
REGISTRATION CHANGES COMPLETED
Please mail completed form to: DMV Change of Address Unit, 60 State Street, Wethersfield, CT 06161-1015
Individual Change of Address/Organ & Tissue Donor Status/Voter Registration Application
About You
You must provide your
name, license/ID
number and birth date.
1
NAME (Last, First, Middle)
BIRTH DATE
OPERATOR LICENSE/ID NUMBER
TELEPHONE NUMBER
Your Residence
Address
This must be a
Connecticut address.
2
STREET ADDRESS
UNIT/APT. #
CITY
STATE
CT
ZIP CODE
06
DMV shares residence address updates with town registrars
of voters so they can update your voting address, if you are
a registered voter.
Check here if you do NOT want your voting address
automatically updated.
Your Mailing
Address
STREET ADDRESS
UNIT/APT. #
Organ and Tissue
Donor Status
3
4
I consent to organ and tissue donation
and wish to be in the donor registry
I no longer wish to be in the donor registry
Your E-mail
Address
5
Check here to remove an e-mail address already on file and have your registration renewal reminders sent to you by mail.
PLATE/VESSEL NO:
PLATE/VESSEL NO:
PLATE/VESSEL NO:
ADDRESS
ADDRESS
ADDRESS
Your
Vehicles/Vessels
ONLY list
vehicles/vessels
garaged somewhere
other than your new
residence address.
(List any additional vehicles on a separate sheet and attach it to this form.)
*All vehicles will be changed to your new residence address unless specified here.*
6
SIGNATURE
X
DATE
Are you a citizen of the United States of America?
YES
NO
Will you be at least 18 years of age on or before election day?
YES
NO
If you checked "NO" in response to either of these questions, do NOT complete below this line as you cannot
register to vote.
Voter
Registration
Application
Section
Do you wish to enroll in a political party?
YES
NAME OF PARTY:
DEMOCRATIC
REPUBLICAN
OTHER:
NO
I do not wish to enroll in a party at this time and will be registered as UNAFFILIATED.
Note: Declaring a party enables you to vote in the party's primary election, which is open only to party members.
You may later choose to switch enrollment to or from a political party.
LEAVING THIS BOX BLANK WILL AUTOMATICALLY RESULT IN SELECTING "UNAFFILIATED".
VOTER DECLARATION - I swear or affirm under penalty of perjury that:
* I am a U.S. Citizen;
* I am at least 17 years old and will be at least 18 years old on or before election day;
* I live in Connecticut at the address shown above;
* I have not been convicted of a disenfranchising felony, or if so, I am eligible to register to vote.
The information that I have provided is true to the best of my knowledge under penalty of perjury. If I have
provided false information, I may be subject to a fine or imprisonment or both under federal or state laws.
By signing this Voter Declaration, I am applying to register to vote or changing my existing party affiliation, and I agree
to allow the signature from my license record to be used as the signature on my voter registration record.
DATE SIGNED
SIGNATURE FOR VOTER REGISTRATION ONLY **
X
** Voter registrations without signatures will not be processed.
ONLY complete this
section if you would
like to apply for voter
registration or if you
are already registered
to vote and want to
change your political
party affiliation.
7
E-MAIL
SIGNATURE REQUIRED
CITY
STATE
ZIP CODE
If different from your
residence address.
DO NOT COMPLETE BELOW THIS LINE UNLESS YOU WANT TO REGISTER TO VOTE OR CHANGE YOUR POLITICAL PARTY AFFILIATION.
Document Specifications
| Fact Name | Details |
|---|---|
| Purpose | The Connecticut B-58 form is used for changing an address and updating organ/tissue donor status. |
| Eligibility | Joint owners can use this form if both operators' license or non-driver ID numbers are provided. |
| Signature Requirement | All applicants must sign and date the form for it to be valid. |
| Address Update Process | Individuals must copy their current registration information and update their address on both their license and registration documents. |
| Mailing Address Notification | In addition to notifying the DMV, individuals should also contact their local post office to update their official mailing address. |
| Governing Laws | The form is governed by Section 14-110 and Section 53a-157b of the Connecticut General Statutes. |
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