Ignition-Interlock-Device-Exemption-Request-DL-4062

A Public Service Agency
IGNITION INTERLOCK DEVICE (IID) EXEMPTION REQUEST
SECTION 1 — DRIVER INFORMATION

FULL NAME (FIRST, MIDDLE, LAST) 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

VIOLATION 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) §23575.3, because I meet all of the following
requirements:
• I do not own a vehicle.
Note: 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.
• 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 conviction.
I 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 §23575.3, when I purchase or gain access to a vehicle.
IMPORTANT: 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.
OUT-OF-STATE EXEMPTION
I am exempt from the installation of an IID pursuant to CVC §23575.3, 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
X
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 Print Clear Form

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.
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. 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.
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.
Go to Page 1 Print Clear Form

DL 4062 (NEW 1/2019) WWW

Ignition-Interlock-Device-Exemption-Request-DL-4062

Uploaded by

Copyright:

Available Formats

Ignition-Interlock-Device-Exemption-Request-DL-4062

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ignition-Interlock-Device-Exemption-Request-DL-4062

Uploaded by

Copyright:

Available Formats

A Public Service Agency

IGNITION INTERLOCK DEVICE (IID) EXEMPTION REQUEST

SECTION 1 — DRIVER INFORMATION

RESIDENCE ADDRESS CITY STATE ZIP CODE

MAILING ADDRESS CITY STATE ZIP CODE

SECTION 2 — CONVICTION INFORMATION

IID PROGRAM EXEMPTION

DL 4062 (NEW 1/2019) WWW Print Clear Form

INSTRUCTIONS FOR OUT-OF-STATE EXEMPTION

Go to Page 1 Print Clear Form

You might also like