[Iowa DOT] 430305: Emergency Contact Information - Request to Submit or Change Information

Emergency Contact Information – Request to Submit or Change Information

Part I. Request to Submit Emergency Contact Information.

Subject to the requirements of Iowa Code section 321.197 and Iowa administrative rule 761—601.3, I request the Iowa DOT to include up to two emergency contact persons in my Iowa driving record and understand the information provided for the emergency contact person(s) will be made available to law enforcement to carry out their official purposes. The emergency contact person’s name and phone number or name and full complete address must be submitted. Forms listing only a name will not be accepted. This form must be signed on the second page.

Part II. Emergency Contact Information.

1. Primary Emergency Contact Information

2. Secondary Emergency Contact Information

Part III. Request to Change Emergency Contact Information.

Pursuant to Iowa Code section 321.197(4) and Iowa administrative rule 761—601.3, I request the Iowa DOT to change my existing emergency contact persons. Please complete Parts I and II of this form to indicate whom should be listed as your emergency contact person(s) in your driving record.

I certify under penalty of perjury and pursuant to the laws of the state of Iowa that the information provided on this form is true and correct.

Signature HereClick to Sign

10/31/2026Click to Sign

Additional Signatures Required

	Signer Details	Me?
Applicant
I'm not a signer listed above

Print Document

Create Your Signature

Sign Now!

Please provide accurate information below to ensure the delivery of the signed copies of the document.

Listed Signers