Fillable Printable Form DS-21 - Interlock Device Installation Confirmation - New York

Form DS-21 - Interlock Device Installation Confirmation - New York

DS-21 (3/15)

DEPARTMENT OF MOTOR VEHICLES ORDERED

INTERLOCK DEVICE INSTALLATION CONFIRMATION

www.dmv.ny.gov

TO BE COMPLETED BY MOTORIST:

NOTE:

You must present a NYS Non-driver ID Card or other photo ID to the installer at the time of installation.

Motorist’s Name: __________________________________________________________________________

Address: __________________________________________________________________________

Date of Birth: __________________________________ NYS Client ID:___________________________

List all vehicles you personally own or operate (do not include vehicles driven for employment):

CERTIFICATION: I understand that I am required to have an interlock device installed on any vehicles I own or

operate, including any subsequent vehicles I may obtain. I certify that the information I have given on this form

is true. I understand that the NYS DMV may contact the installer indicated to validate the information provided.

IMPORTANT: Making a false statement on this disclosure, or in any proof or statement in connection with it, or de-

ceiving or substituting, or causing another person to deceive or substitute in connection with this disclosure, may

subject you to criminal prosecution for a misdemeanor or felony under the Vehicle & Traffic Law and/or Penal

Law.

On ____________________, I installed an Ignition Interlock Device Model ___________________________,

certified by the NYS Department of Health and approved by NYS Division of Criminal Justice Services (DCJS),

in the above named motor vehicle(s). All vehicle operators have been trained in the proper use of the device and

of all maintenance requirements..

IMPORTANT: Making a false statement on this disclosure, or in any proof or statement in connection with it, or de-

ceiving or substituting, or causing another person to deceive or substitute in connection with this disclosure, may

subject you to criminal prosecution for a misdemeanor or felony under the Vehicle & Traffic Law and/or Penal Law.

TO BE COMPLETED BY INSTALLER:

Installer Name: __________________________________________________________________________

Installer Address: __________________________________________________________________________

Phone Number: ___________________________________

YEAR VEHICLE IDENTIFICATION NUMBERMAKE

Motorist Signature: Date:

Installer Signature: Date:

INSTALLER: After installation of device, please fax a copy of the completed form to (518) 473-8229 or

email to dmv.sm.interlock@dmv.ny.gov and return the original to the motorist.

MOTORIST: Bring this completed form, along with all other required paperwork, to a Motor Vehicles

office to obtain a New York State license with a Problem Driver Interlock Restriction.

INSTRUCTIONS: