DMV Intake Form - Sample Examples by Case Type
FR – Financial Responsibility Case
Case assigned: Rodney Gould
Full Name: Shawn Miller
Date of Birth: 1990-06-15
Driver’s License Number: D1234567
U.S. Citizen / Resident?: Yes
Commercial Driver’s License Number (if applicable): N/A
Home Address, City, State, Zip Code: 123 Elm St, Sacramento, CA 95814
Cell Phone, Home Phone: 555-123-4567 / 555-987-6543
Email Address, Fax Number: [Link]@[Link] / 555-222-3333
Preferred Contact Method: Email
Date of Incident: 2025-08-12
Time of Incident: 3:45 PM
Location of Incident: I-80 Westbound, Exit 14
Description of Experience: Rear-ended by uninsured driver
Case Type: FR
Amount Due: $4500
Case summary: Insurance dispute following accident
Is your license currently suspended?: No
Suspension Date: N/A
Suspension Date per DMV Notice: N/A
License Status Details: Valid
Payment Terms or Conditions: $500 down, $4000 if failed
client vehicle insurance status: Active
Family Member or Representative Name: Lisa Miller
Their Contact Info (Phone, Email, Address): 555-444-5555 / lisa.m@[Link] / same
address
Relationship to Client: Sister
Type of insurance: Full coverage
deductible amount: $1000
Damage Description: Rear bumper, trunk
Insurance claim status: Pending
Liability Cover Status: Confirmed
NEG – Negligence Case
Case assigned: Rodney Gould
Full Name: Jordan Smith
Date of Birth: 1985-03-22
Driver’s License Number: S7654321
U.S. Citizen / Resident?: Yes
Commercial Driver’s License Number (if applicable): C9876543
Home Address, City, State, Zip Code: 456 Oak Ave, Fresno, CA 93722
Cell Phone, Home Phone: 555-321-6789 / 555-654-3210
Email Address, Fax Number: [Link]@[Link] / 555-333-4444
Preferred Contact Method: Phone
Date of Incident: 2025-07-20
Time of Incident: 11:15 AM
Location of Incident: Intersection of Main & 5th St
Description of Experience: Alleged failure to yield
Case Type: NEG
Amount Due: $2500
Case summary: Challenging negligence claim
Is your license currently suspended?: Yes
Suspension Date: 2025-08-01
Suspension Date per DMV Notice: 2025-08-05
License Status Details: Suspended
Payment Terms or Conditions: $500 down, $2000 if failed
client vehicle insurance status: Active
Family Member or Representative Name: Mark Smith
Their Contact Info (Phone, Email, Address): 555-777-8888 / mark@[Link] / same
address
Relationship to Client: Brother
Points on license: 4
Driving violations history: Speeding (2023), Red light (2024)
commercial License holder: Yes
APS – Admin Per Se Case
Case assigned: Rodney Gould
Full Name: Emily Johnson
Date of Birth: 1992-11-05
Driver’s License Number: J2345678
U.S. Citizen / Resident?: Yes
Commercial Driver’s License Number (if applicable): N/A
Home Address, City, State, Zip Code: 789 Pine Rd, San Diego, CA 92103
Cell Phone, Home Phone: 555-888-9999 / 555-111-2222
Email Address, Fax Number: emily.j@[Link] / 555-666-7777
Preferred Contact Method: Email
Date of Incident: 2025-09-01
Time of Incident: 1:30 AM
Location of Incident: Downtown San Diego
Description of Experience: DUI checkpoint, breath test 0.09%
Case Type: APS
Amount Due: $2500
Case summary: Contesting DUI suspension
Is your license currently suspended?: Yes
Suspension Date: 2025-09-02
Suspension Date per DMV Notice: 2025-09-05
License Status Details: Temporary license issued
Payment Terms or Conditions: $500 down, $2000 if failed
client vehicle insurance status: Active
Family Member or Representative Name: Sarah Johnson
Their Contact Info (Phone, Email, Address): 555-999-0000 / sarah@[Link] / same
address
Relationship to Client: Mother
P&M – Physical & Mental Condition Case
Case assigned: Rodney Gould
Full Name: Robert Lee
Date of Birth: 1978-04-10
Driver’s License Number: L8765432
U.S. Citizen / Resident?: Yes
Commercial Driver’s License Number (if applicable): N/A
Home Address, City, State, Zip Code: 321 Birch Blvd, Oakland, CA 94607
Cell Phone, Home Phone: 555-444-1111 / 555-222-3333
Email Address, Fax Number: [Link]@[Link] / 555-555-6666
Preferred Contact Method: Phone
Date of Incident: N/A
Time of Incident: N/A
Location of Incident: N/A
Description of Experience: DMV requested medical evaluation
Case Type: P&M
Amount Due: $3000
Case summary: Review of epilepsy condition
Is your license currently suspended?: No
Suspension Date: N/A
Suspension Date per DMV Notice: N/A
License Status Details: Valid with restrictions
Payment Terms or Conditions: $500 down, $2500 if failed
client vehicle insurance status: Active
Family Member or Representative Name: Linda Lee
Their Contact Info (Phone, Email, Address): 555-333-7777 / linda@[Link] / same
address
Relationship to Client: Wife
List of client affected medical condition: Epilepsy
doctor finding: Stable with medication
medical test undergone: EEG, MRI
