Fillable Printable Form DS-871 - Article 19-A Driver Notification to Employer - New York

Form DS-871 - Article 19-A Driver Notification to Employer - New York

Driver’s Name: ____________________________________________________________________________________

Driver’s Address:____________________________________________________________________________________

Client/License ID Number (from Driver License) __________________________________ State: ________

Date of:

£ Misdemeanor/Felony ______________________

£ License Revocation, Suspension, Withdrawal ____________________________

£ Accident ______________________

£ Traffic Infraction _______________________________

Date of Conviction (if applicable):

£ Misdemeanor/Felony ____________________________ £ Traffic Infraction ________________________

Vehicle Operated: (check one) £ CMV £ Non-CMV

Location of Misdemeanor, Felony, Accident or Traffic Infraction (City/Town/County/State): __________________________

_________________________________________________________________________________________________

Description of Misdemeanor, Felony, Accident or Traffic Infraction: ____________________________________________

_________________________________________________________________________________________________

Driver’s Signature: ______________________________________________________ Date:____________________

Received by: _____________________________________________________________ Date:____________________

______________________________________________________________

ARTICLE 19-A DRIVER NOTIFICATION TO EMPLOYER

www.dmv.ny.gov

DS-871 (6/15)

Under the provisions of Article 19-A of the NYS Vehicle & Traffic Law (§509-i)

I HEREBY NOTIFY MY EMPLOYER OF THE FOLLOWING INFORMATION:

NOTE: This form may be used to meet the reporting requirements of Section 6.21 of the Commissioner’s Rules and Regulations.

MISDEMEANOR/FELONY CONVICTIONS OR LICENSE REVOCATIONS, SUSPENSIONS, OR WITHDRAWALS

A driver who receives a notice that his or her license, permit or privilege to operate a motor vehicle has been revoked, suspended, or

withdrawn or who is convicted of a misdemeanor or a felony in any state or foreign jurisdiction shall notify the employer(s) of the contents

of the notice or of the nature of the conviction before the end of the business day following the day he or she received the notice, or the

day the conviction occurred.

A driver who fails to notify his or her employer(s) of such suspension, revocation or misdemeanor/felony conviction shall be subject to a

five (5) working day suspension, or a suspension equivalent to the number of working days such driver was not in compliance with Part 6,

whichever is longer.

ACCIDENT OR TRAFFIC INFRACTION CONVICTIONS

Any driver who is involved in an accident as defined in Section 6.2 of Part 6 of the Commissioner’s Rules and Regulations, or who is

convicted of a traffic infraction in any state or foreign jurisdiction shall notify his or her employer(s) within five (5) working days from the

date of conviction or such accident.

A driver who fails to notify his or her employer(s) of such traffic infraction conviction or accident within the five (5) working day period

shall be subject to a five (5) working day suspension. Working day, for the purposes of this section, shall mean any day in which a bus

driver is scheduled to work, excluding regularly assigned days off.

(Last)

(Street)

(Signature of Carrier Representative)

(Print Name)

(City) (State) (Zip Code)

(First) (M.I.)