Fillable Printable Form MV-80W - Application for Tinted Window Exemption - New York

Form MV-80W - Application for Tinted Window Exemption - New York

www.dmv.ny.gov

New York State Department of Motor Vehicles

APPLICATION FOR TINTED WINDOW EXEMPTION

INSTRUCTIONS:

Please provide the following information as it appears on the vehicle registration.

If a medical exemption is requested for someone other than the registered owner of the vehicle, please provide the

following information about that person.

The front windshield and side windows on both sides of any vehicle operating in New York State must allow at least 70% of any

light to pass through. The rear window may allow less than 70% of any light to pass through if the vehicle has mirrors on both

sides that can be adjusted so the driver has a clear view of the road and traffic conditions behind the vehicle. The rear side

windows of any station wagon, sedan, hardtop, coupe, hatchback or convertible must also allow 70% of any light to pass through.

The law provides an exemption

for any person who, for medical reasons, must be shielded from direct sunlight. The person who

requests an exemption may be either the driver or someone who is a regular passenger in the vehicle.

NYS Health Department regulations specify that

only the following medical conditions can be used to justify an exemption from

the limits on light transmittance:

l porphyria

l xeroderma pigmentosa

l severe drug photo-sensitivity

To request a medical exemption, send the following three items to the address at the bottom of this page:

l this completed application; and

l a photocopy of the vehicle registration receipt; and

l a physician’s statement, on physician’s letterhead (including the New York State Professional License Number), describing

the presence of a medical condition which requires that the applicant or someone other than the applicant be shielded from

sunlight. If the statement is from an out-of-state physician, the name of the state in which the physician is licensed, and

his/her license, certificate or registration number, must be included.

Please Note: Based on the medical information submitted, our reviewer may ask for further medical details, or may request

additional information from a pertinent sub-specialist, ex: dermatologist; optometrist

I am requesting a tinted window exemption certificate, as allowed by Section 375 (12-a) (c) of the New York State Vehicle and

Traffic Law.

Vehicle Registrant’s Signature

ç ________________________________________________________

(Sign Name in Full)

Last Name

Address (Number and Street)

City State Zip Code

First M.I.

Apt. #

Last Name

Address (Number and Street)

City State Zip Code

First M.I.

Apt. #

Return this application to: Department of Motor Vehicles, Driver Improvement Bureau, Medical Review Unit,

6 Empire State Plaza, Room 337, Albany NY 12228

MV-80W (12/12)