IGNITION INTERLOCK DEVICE (IID) EXEMPTION REQUEST

APPLICANT INFORMATION

Full Legal Name: _____________________________________________

Driver's License Number: _____________________________________________

State of Issuance: _____________________________________________

Date of Birth: _____________________________________________

Social Security Number (last 4): XXX-XX-_________

Current Address: _____________________________________________

City, State, ZIP: _____________________________________________

Phone Number: _____________________________________________

Email Address: _____________________________________________

CASE/ORDER INFORMATION

Court Case Number (if applicable): _____________________________________________

DMV Case/Reference Number: _____________________________________________

Date of DUI/DWI Conviction or Action: _____________________________________________

Date IID Requirement Ordered: _____________________________________________

Required IID Period: _____________________________________________

Current IID Provider (if installed): _____________________________________________

CURRENT IID STATUS

☐ IID has been installed and is currently operational
☐ IID has not yet been installed
☐ IID installation deadline is approaching
☐ IID requirement is preventing license reinstatement

IID Installation Date (if applicable): _____________________________________________

Time Served with IID: _____________________________________________

TYPE OF EXEMPTION REQUESTED

Full Exemption Request

☐ Complete exemption from IID requirement

Partial/Modified Exemption Request

☐ Exemption for specific vehicle(s) only
☐ Reduced IID requirement period
☐ Exemption for employer-owned vehicles
☐ Alternative monitoring program
☐ Medical exemption
☐ Financial hardship exemption
☐ Other: _____________________________________________

GROUNDS FOR EXEMPTION

Medical Exemption

☐ I have a medical condition that prevents me from providing adequate breath samples
☐ I have a physical disability that prevents proper use of the device
☐ The device interferes with necessary medical equipment
☐ I have a respiratory condition affecting testing ability

Medical Condition: _____________________________________________

How Condition Affects IID Use:
_____________________________________________
_____________________________________________
_____________________________________________

Physician Information:

Name: _____________________________________________

Address: _____________________________________________

Phone: _____________________________________________

License Number: _____________________________________________

☐ Medical documentation attached

Employer Vehicle Exemption

☐ My employment requires driving employer-owned vehicles
☐ My employer will not permit IID installation on their vehicles
☐ Installing IID on employer vehicles is impractical

Employer Information:

Company Name: _____________________________________________

Address: _____________________________________________

Supervisor Name: _____________________________________________

Phone: _____________________________________________

Job Title: _____________________________________________

Driving Requirements:
_____________________________________________
_____________________________________________

Employer Notification of DUI:
☐ Employer has been notified of my DUI conviction
☐ Employer is aware of IID requirement
☐ Employer refuses to allow IID on company vehicles

☐ Employer verification letter attached

Alternative Conditions Proposed:
☐ Will not drive employer vehicles
☐ Will only drive employer vehicles during work hours
☐ Employer will provide supervision while driving
☐ Will use personal IID-equipped vehicle for personal use
☐ Other: _____________________________________________

No Vehicle Ownership/Access Exemption

☐ I do not own a motor vehicle
☐ I do not have regular access to any motor vehicle
☐ I do not intend to drive during the restriction period
☐ I use only public transportation

Explanation:
_____________________________________________
_____________________________________________

☐ Declaration of non-driving attached
☐ Proof of public transportation use attached

Financial Hardship Exemption

☐ I cannot afford the IID installation and monthly fees
☐ IID costs would create undue financial hardship

Monthly IID Costs:
- Installation fee: $_____________
- Monthly monitoring/lease: $_____________
- Calibration fees: $_____________
- Total monthly cost: $_____________

Monthly Income: $_____________

Monthly Expenses: $_____________

☐ Financial documentation attached (pay stubs, tax returns, etc.)
☐ Public benefits documentation attached

Vehicle Incompatibility Exemption

☐ The IID cannot be properly installed on my vehicle
☐ My vehicle's electrical system is incompatible
☐ Installation would cause damage to the vehicle
☐ Vehicle is a classic/antique incompatible with IID technology

Vehicle Information:

Year: _____________ Make: _____________ Model: _____________

VIN: _____________________________________________

Incompatibility Explanation:
_____________________________________________
_____________________________________________

☐ IID installer letter confirming incompatibility attached

Completion of Requirement Exemption

☐ I have completed the required IID period
☐ I have met all conditions of my IID requirement
☐ Early removal is warranted based on compliance

Evidence of Compliance:
☐ No violations during IID period
☐ All calibrations completed on time
☐ No failed tests or lockouts
☐ Completed all required programs

☐ IID compliance report attached

STATE-SPECIFIC EXEMPTION PROVISIONS

CALIFORNIA

Exemption Eligibility:
- Employer vehicle exemption available with employer certification
- Medical exemption for documented conditions affecting breathing
- No personal vehicle exemption with declaration not to drive
- Must obtain IID restriction on license even if not installing

Required Documentation:
- DL 4062 (Employer Exemption Certification)
- Medical certification from licensed physician
- Verification of Employment (VOE) form

Agency: DMV Mandatory Actions Unit
Note: Pilot counties may have different requirements

TEXAS

Exemption Eligibility:
- Occupational license may be issued without IID in some cases
- Medical exemption with physician certification
- Financial hardship consideration by court
- Employer vehicle exemption possible with court approval

Required Documentation:
- Court order granting exemption
- Medical records and physician statement
- Financial hardship documentation
- Employer letter and verification

Agency: Texas Department of Public Safety (DPS)
Note: Judge has discretion on exemptions; must petition court

FLORIDA

Exemption Eligibility:
- Employer vehicle exemption with employer consent and notification
- Medical exemption for qualifying conditions
- No exemption for personal vehicle requirement
- Second or subsequent offense: limited exemption options

Required Documentation:
- Employer affidavit (Form HSMV 72038)
- Medical certification
- Proof of IID installation on personal vehicle (if applicable)

Agency: DHSMV Bureau of Administrative Reviews
Note: First offense hardship license may not require IID in all cases

NEW YORK

Exemption Eligibility:
- Employer vehicle exemption with conditions
- Medical exemption with documentation
- Pre-conviction conditional license may have different requirements
- Post-conviction: limited exemption options

Required Documentation:
- Court motion for exemption
- Medical certification on prescribed form
- Employer letter on company letterhead
- Proof of alternative transportation

Agency: DMV and sentencing court
Note: Court approval typically required for exemptions

PROPOSED ALTERNATIVE CONDITIONS

If full exemption is not granted, I propose the following alternative conditions:

☐ Installation of IID on my personal vehicle only (exempting employer vehicles)
☐ Reduced IID period of _____________ months
☐ Increased monitoring/reporting requirements
☐ Additional alcohol education/treatment programs
☐ Regular alcohol testing (ETG, PBT, etc.)
☐ SCRAM continuous alcohol monitoring device instead
☐ GPS monitoring
☐ Restricted driving hours
☐ Restricted driving locations
☐ Other: _____________________________________________

SUPPORTING DOCUMENTATION ATTACHED

☐ Court order requiring IID (copy)
☐ DMV suspension/restriction notice (copy)
☐ Medical records and physician letter
☐ Employer verification letter
☐ Employer affidavit (state form if required)
☐ IID installer incompatibility letter
☐ Financial hardship documentation
☐ Proof of public benefits
☐ Vehicle registration
☐ IID compliance/history report
☐ Proof of program completion
☐ Declaration of non-driving
☐ Other: _____________________________________________

DECLARATION

I, [FULL LEGAL NAME], declare under penalty of perjury under the laws of the State of [STATE] that:

1. The information provided in this request is true and correct.
2. I understand that providing false information may result in denial of this request and additional penalties.
3. I understand that if granted an exemption, I must comply with all conditions imposed.
4. I understand that any exemption may be revoked if I violate conditions or applicable law.
5. I understand that even with an exemption, I am prohibited from driving under the influence.
6. I agree to notify the DMV/Court of any changes in circumstances affecting this exemption.

For Employer Vehicle Exemption:
☐ I acknowledge that I am only authorized to drive employer vehicles for work purposes
☐ I acknowledge that I must have IID on any personal vehicle I operate
☐ I acknowledge that my employer has been informed of my DUI conviction

For Medical Exemption:
☐ I authorize release of medical information necessary to verify my condition
☐ I will provide any additional medical documentation requested

For No Vehicle/Non-Driving Exemption:
☐ I will not drive any motor vehicle during the exemption period
☐ I will immediately report any change in vehicle ownership or access
☐ I understand that driving without an IID (if exempted) may result in additional penalties

Signature: _____________________________________________

Printed Name: _____________________________________________

Date: _____________________________________________

EMPLOYER CERTIFICATION (If Applicable)

I, [EMPLOYER REPRESENTATIVE NAME], certify that:

☐ [EMPLOYEE NAME] is employed by [COMPANY NAME]
☐ The employee's job duties require driving company-owned vehicles
☐ The company is unable/unwilling to permit IID installation on company vehicles
☐ The company has been informed of the employee's DUI conviction
☐ The employee is authorized to drive company vehicles only for business purposes
☐ The company will notify the DMV/Court if employment is terminated

Employer Representative Signature: _____________________________________________

Printed Name: _____________________________________________

Title: _____________________________________________

Company Name: _____________________________________________

Company Address: _____________________________________________

Phone: _____________________________________________

Date: _____________________________________________

SUBMISSION INFORMATION

Submit to: [State DMV/Court as appropriate]

Address: _____________________________________________

Required Fee (if any): $_____________

Deadline: _____________________________________________

FOR OFFICIAL USE ONLY

This template is provided for general informational purposes. IID exemption requirements and eligibility vary by state and individual circumstances. Always verify current requirements with your state's DMV and/or court.