Fillable Printable Form DS-7 - Request for Driver Review - New York

Form DS-7 - Request for Driver Review - New York

REQUEST FOR DRIVER REVIEW

www.dmv.ny.gov

INSTRUCTIONS:

l This form is to be used by concerned citizens to report a driver who appears to be unable to drive safely. (Law enforcement personnel must

use form DS-5, “Police Agency Request for Driver Review”; physicians must use form DS-6, “Physician’s Reporting Form”).

l The Department will not act on your request unless you complete all four parts below and on Page 2, and provide all required information.

Please provide as much factual detail as possible.

l Sign the completed original form and mail it to:

Medical Review Unit

New York State Department of Motor Vehicles

6 Empire State Plaza, Room 337

Albany, NY 12228

l Be aware that the review you are requesting may lead to the suspension or revocation of the driver’s license of the person you are reporting.

PART 1 - Identification of the person whose ability to drive is in question (Please print.)

DS-7 (6/15)

PAGE 1 OF 2

Last Name (Required)

(Part 3 is continued on Page 2)

Street Address (Required)

City (Required) State (Required) Zip Code

Make of Vehicle the

Person Normally Drives

Color of

Vehicle

License Plate

Number

First Name (Required) M.I. Date of Birth (if not known, give approximate age) -

(Required)

PART 2 - Your identification (Please print.)

A representative of the NYS DMV may contact you concerning your request for driver review.

PART 3 - Your reasons for reporting this driver

Explain why you feel the person you identified in Part 1 should have his/her driving abilities reviewed. Be as specific as possible, and include

specific incidents, observations, dates, locations, etc.

Your Name (Print name in full) - (Required)

Your relationship to the driver you are reporting:

o Daughter o Son o Sister o Brother o Spouse o Mother o Father o Neighbor

o Other (explain)

Your Home Address (Include Street & Number) - (Required)

City (Required) State (Required) Zip Code (Required)

Your Date of Birth (Required) Client ID No. (9-digit number from your NYS Driver License or

Non-Driver ID card)

Your Daytime Telephone Number (Area Code) - (Required)

PART 3 - (Continued from Page 1)

If you know other people who agree with your assessment of this driver, who DMV may contact, please identify them below:

Name Address Daytime Telephone Number

PART 4 - CERTIFICATION:

I certify that the information I provided above is true and accurate. I understand that any false statement given by me may be punishable by law.

(Your Signature - Sign name in full) (Date - Month/Day/Year)

DS-7 (6/15)

PAGE 2 OF 2

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