Fillable Form DMV 06-104 Nebraska Driver's License Replacement

What is the Nebraska Driver’s License Replacement form?

The Nebraska Driver’s License Replacement form is used by residents of Nebraska who have misplaced or lost their driver’s license. While the form is mainly used to apply for the replacement of a driver’s license, residents may also use it to apply for a driver’s permit and State Identification Card.

How to fill out the Nebraska Driver’s License Replacement form?

The Nebraska Driver’s License Replacement form consists of two pages that you need to fill out completely. Follow the instructions below to answer the form accurately.

Date of Birth

Enter your date of birth in the following format: Month, Day, Year.

Social Security Number

Enter your unique nine-digit Social Security Number.

Legal Name

Enter your full legal name in the following format: Last Name, First Name, Middle Initial, Suffix.

Current Residential Address Required

Enter your current residential address, including the Street address or Route and P.O. Box, City, State, and ZIP code.

Current Mailing Address

If different from your residential address, enter your current mailing address, including City, State, and ZIP code.

Country Number

Enter your County Number.

Gender

Select your assigned gender at birth. Mark the “M” checkbox if male or the “F” checkbox if female.

Height

Enter your height in Feet and Inches.

Weight

Enter your weight.

Eye Color

Enter the natural color of your eye.

Hair Color

Enter the natural color of your hair.

Race

Select your race by marking the appropriate checkbox. You may mark the “Black,” “White,” “American Indian,” “Asian or Pacific Islander,” “Hispanic,” or “Other” checkbox.

For the purpose of complying with Neb. Rev. Stat. 60-484.04, I attest:

I am a citizen of the United States

If applicable, mark the “Yes” checkbox; otherwise, mark “No.”

I am not a citizen of the United States, but do have lawful status and agree to provide valid documentary evidence of such as outlined in 60-4,144

If applicable, mark the “Yes” checkbox; otherwise, mark “No.”

You may or may not answer the following motor voter and veteran questions:

Item 1A

Mark the “Yes” checkbox if you wish to register to vote as part of the application process; otherwise, mark “No.”

Item 1A1

Select your Party Affiliation. You may mark the “Republican,” “Democratic,” “Libertarian,” or “Non-Partisan (no party).”

Item 1B

Mark the “Yes” checkbox if you wish to have the word “Veteran” displayed on the front of your operator’s license or state identification card to show that you served in the armed forces of the United States; otherwise, mark “No.”

You may answer the following organ and tissue donation questions:

Item 2

Mark the “Yes” checkbox if you wish to include your name in the Donor Registry of Nebraska and donate your organs and tissues at the time of your death; otherwise, mark “No.”

Item 3

Mark the “Yes” checkbox if you wish to receive additional specific information regarding organ and tissue donation; otherwise, mark “No.”

Item 4

Mark the “Yes” checkbox if you wish to donate $1 to promote the Organ and Tissue Donor Awareness and Education Fund; otherwise, mark “No.”

If you are applying for a State ID Card, do not answer the following items:

Item 5

Mark the respective “Yes” checkboxes for the conditions that happened to you within the last three months; otherwise, mark the respective “No” checkboxes. Provide a date for items that require it.

a. lost voluntary control or consciousness

b. experienced vertigo or multiple episodes of dizziness or fainting

c. disorientation

d. seizures

e. impairment of memory, memory loss

Item 6

Mark the respective “Yes” checkboxes for the conditions that you experience which affect your ability to operate a motor vehicle due to loss or impairment; otherwise, mark the respective “No” checkboxes.

a. foot/leg

b. upper body strength

c. range of motion/mobility

d. hand/arm

e. neurological/neuromuscular disease

Item 7

Mark the “Yes” checkbox if since the issuance of your last license/permit your health or medical condition worsened; otherwise, mark “No.”

If you are applying for a school learner’s permit or a school permit, answer the following item:

Mark the “Yes” checkbox if your home or the school you attend is in a city of 5,000 or less; otherwise, mark “No.”

Sign and provide the date when you signed the form.

How to apply for a Nebraska Driver’s License Replacement?

You have several options to apply for a Nebraska Driver’s License replacement. The following instructions are based on the information on the official Nebraska DMV website: dmv.nebraska.gov. You may visit the website for more detailed instructions.

Online

You can obtain a replacement online if you hold a driver’s license, Ignition Interlock Permit, or State ID Card if you:

• do not need to change your name, photo, or physical description;
• have not obtained more than two replacements online within the last five years; or
• do not want to change your CDL self-certification category type.

You will be needing documents and payment items to complete your request online.

In-Person

You can get your replacement at any Department of Motor Vehicle (DMV) office. You will need to bring your Nebraska Driver’s License Replacement form, proof of identification, two forms of proof of address, and payment for license fees.

Upon completion of processing and payment of the fee, the County Treasurer will issue you a 30-day receipt, with driving privileges if appropriate. Your driver’s license, permit, or State ID Card will be mailed to you within 14 business days. If you don't receive your license, permit, or ID card within 20 days, contact Driver Licensing Services at 402-471-3861.

Once a replacement document has been issued, the previously issued document will be invalid and cannot be used as proof of identification.

Out-of-State

You may obtain by mail a replacement license, permit, or State ID Card if you are outside Nebraska at the time of application.

You will need a filled-out Operators License Out of State Renewal data form, proof of identification, two forms of proof of address, payment for license fees.

Contact the Driver Licensing Services Home Office in Lincoln for questions regarding the out-of-state application.