Form PS31083 template
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Last Use Statement
The document is a form for individuals in Minnesota to provide personal information for identification purposes and to enroll in the Ignition Interlock Program or complete rehabilitation requirements as outlined by Minn. R. 7503.1725(3) and Minn. R. 7503.1700, Subp. 4. The form includes fields for date of birth, driver's license number, city, address, daytime phone number, abstinence date, signatures, and county. Individuals are required to attest that they have not consumed alcohol or controlled substances since the attested abstinence date and acknowledge the consequences of providing false information. The document also includes a Tennessen Warning explaining the purpose of supplying the requested information and the potential consequences of refusing. DPS may disclose personal information for public safety reasons as outlined in 18 U.S.C § 2721 and Minn. Stat. § 171.12.
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