Transcription of ) Exemption Request
1 A Public Service Agency IGNITION INTERLOCK DEVICE (IID) Exemption Request SECTION 1 DRIVER INFORMATION FULL NAME (FIRST, MIDDLE, L AST) DATE OF BIRTH DRIVER LICENSE NUMBER OR FILE NUMBER RESIDENCE ADDRESS CITY STATE ZIP CODE MAILING ADDRESS CITY STATE ZIP CODE SECTION 2 CONVICTION INFORMATION VIOL ATION DATE CONVICTION DATE SECTION(S) VIOLATED DOCKET NUMBER SECTION 3 Exemption Please indicate the Exemption for which you are applying by checking the appropriate box. IID PROGRAM Exemption I am exempt from the installation of an IID pursuant to California Vehicle Code (CVC) , because I meet all of the following requirements: I do not own a : If you own a vehicle(s) that does not run or for which you have an approved planned non-operation (PNO), you do not qualify for an Exemption .
2 I do not have access to a vehicle at my place of residence. I no longer have access to the vehicle used when I was arrested for the violation that resulted in my acknowledge that I am: Only allowed to drive a vehicle that is equipped with a functioning, certified IID. Required to have a valid driver license before I can drive. Immediately subject to the requirements of CVC , when I purchase or gain access to a : If you are eligible and wish to file an Exemption under the IID Program Exemption , complete and mail this form to the address listed on Page 2 within 30 days from the date of your suspension or revocation notice. Exemptions will not be granted for requests postmarked after 30 days from the date of your suspension or revocation notice.
3 OUT-OF-STATE Exemption I am exempt from the installation of an IID pursuant to CVC , because I am not a resident of California as specified in CVC 23575(g). IMPORTANT: If you are eligible and wish to file an Exemption under the Out-Of-State- Exemption , you must include at least one acceptable out-of-state residency document when submitting this form to the address listed on Page 2. SECTION 4 CERTIFICATION I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. SIGNATURE DATE Upon receipt, DMV will review your application and any supporting documents. DMV will provide you with documentation regarding the approval or denial of your application. DL 4062 (NEW 1/2019) WWW X GENERAL INFORMATION AND INSTRUCTIONS An Exemption will not be granted if this information is incorrect or if it is determined that at the time you become eligible to reinstate your driving privilege, you do not meet all of the Exemption requirements.
4 Complete and submit this form to the Department of Motor Vehicles (DMV) at the address below. If you have any questions regarding eligibility requirements and/or how to complete this form, call Mandatory Actions Unit at (916) 657-6525. Department of Motor Vehicles Mandatory Actions Unit, MS J233 PO Box 942890 Sacramento, CA 94290-0001 INSTRUCTIONS FOR OUT-OF-STATE Exemption By choosing the Out-Of-State- Exemption , you must include at least one acceptable out-of-state residency document when submitting this form to the above address. An acceptable out-of-state residency document is one of the following documents that lists the applicant s first and last name, and the residence address matches the residence address listed on this form, which is located outside of the State of California: 1.
5 Receipts for payment of resident tuition at a public institution of higher education or school records. 2. Home utility bill including cellular phone bill. 3. Documents issued by a licensing authority indicating a current application for a driver license in the state of residence. 4. Official voter registration documents. 5. Official document issued by a governmental agency that can be used by the department to prove residency. 6. Rental or lease agreement with the signature of the owner/landlord and the tenant/resident. 7. Deed or title to residential real property. 8. Mortgage bill. 9. Filing of homeowner s property tax Exemption or homestead Exemption certificate. 10. Medical document . 11. Employment document . 12. Insurance document , including medical, dental, vision, life, home, rental, and vehicle.
6 13. Change of Address Confirmation by the United States Postal Service. 14. Property tax bill or statement. 15. Faith based document that includes the name and address of the issuing organization. 16. Tax return documents. 17. Record of a financial institution. 18. Court documents that list the applicant as a resident outside of California. DL 4062 (NEW 1/2019) WWW
