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Application For Critical Need Restriction DS 694 - California
| Application For Critical Need Restriction Form. This is a California form and can be used in Administrative Hearings And Reexaminations Statewide . |
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STATE OF CALIFORNIA DEPARTMENT OF MOTOR VEHICLES ® A Public Service Agency APPLICATION FOR CRITICAL NEED RESTRICTION [Section 13353.8(a) VC] Submit COMPLETED application to the Driver Safety Actions Unit, 2570 24th Street, M/S J256, Sacramento, CA 95818, Telephone: (916) 657-6452. DMV approval is required prior to issuance of a restricted license. If approved, a $100 reissue fee must be paid and a California Insurance Proof Certificate (SR-22) must be submitted to the department prior to issuance of a restricted license; proof of financial responsibility must be maintained for three (3) years. Do not present in person at any DMV field office. ATTACH SEPARATE SHEET IF MORE SPACE IS NEEDED. Incomplete information may delay the issuance of this license. Application can only be approved if driver is legally present in California and specific HARDSHIP conditions are shown to exist. ALL other transportation must be inadequate. Action taken by the department must be pursuant to § 13353.2 & 13388 of the Vehicle Code AND applicant must have been under 21 years of age at the time of arrest/detainment and have submitted to a Preliminary Alcohol Screening test, or other chemical test, as requested by a peace officer. A 30 day mandatory suspension is required prior to issuance of a hardship license. SECTION 1 -- STATEMENT OF FACTS BY APPLICANT (OR PARENTS, IF UNDER 18 YEARS OF AGE) CHECK ONE OR MORE OF THE FOLLOWING REASONS FOR APPLICATION AND COMPLETE THE CORRESPONDING SECTION(S): A, B, C, OR D A. For Family Illness B. To and From School C. To and From Work DATE OF BIRTH D. For Family Enterprise DAY PHONE APPLICANT'S FULL NAME DL NUMBER HOME PHONE ( STREET ADDRESS AND CROSS STREET CITY ) ( ZIP CODE ) PART A -- DESCRIPTION OF CURRENT TRANSPORTATION AND NEEDS LIST APPLICANT'S ESSENTIAL DRIVING NEEDS DISTANCE FROM APPLICANT'S RESIDENCE TO NEAREST PUBLIC TRANSPORTATION DESCRIBE BEST TRANSPORTATION ROUTE, COMPANY NAME, PHONE NO., NO. OF INDIVIDUAL LINES LIST NAMES AND DRIVER LICENSE NUMBERS OF ALL DRIVERS IN THE HOUSEHOLD EXPLAIN SPECIFICALLY WHY EACH DRIVER IN THE HOUSEHOLD CANNOT DO THE REQUIRED DRIVING. INCLUDE DAILY WORK OR SCHOOL AND TRAVEL SCHEDULE OF EACH DRIVER, HOURS AND LOCATION OF EMPLOYMENT, DISTANCE FROM HOME AND APPLICANT'S SCHOOL. INCLUDE NUMBER OF EMPLOYEES IF SELF EMPLOYED. USE SEPARATE SHEET IF NECESSARY IF HOUSEHOLD INCLUDES NON-DRIVING ADULT OR MINOR OLDER THAN APPLICANT, GIVE NAME AND RELATIONSHIP TO APPLICANT AND EXPLAIN WHY PERSON CANNOT/DOES NOT DRIVE. (IF MEDICAL REASON, SEPARATE STATEMENT OF FACTS BY PHYSICIAN NEEDED.) EXPLAIN WHY CARPOOLS, TAXIS, BICYCLES, WALKING, VANPOOLS AND ANY OTHER PRIVATE TRANSPORTATION CANNOT BE USED. PART B -- ADDITIONAL INFORMATION REQUIRED IF REQUEST IS DUE TO FAMILY ILLNESS RELATIONSHIP BETWEEN THE ILL PERSON AND THE APPLICANT DOES THIS ILLNESS PREVENT THIS PERSON FROM DRIVING AND FOR HOW LONG? Yes If yes, how long? DESCRIBE CURRENT TRANSPORTATION ARRANGEMENTS No PART C -- ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON NEED FOR TRANSPORTATION TO AND FROM SCHOOL CHECK APPROPRIATE BOX DESCRIBE CURRENT TRANSPORTATION ARRANGEMENTS High School College/University Other: EXPLAIN THE CIRCUMSTANCES THAT NOW MAKE THE APPLICANT'S OPERATION OF A MOTOR VEHICLE ESSENTIAL PART D -- ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON NEED FOR TRANSPORTATION TO AND FROM WORK EXPLAIN CIRCUMSTANCES THAT NOW MAKE APPLICANT'S INCOME ESSENTIAL IN THE SUPPORT OF THE FAMILY DESCRIBE CURRENT TRANSPORTATION ARRANGEMENTS APPLICANT'S NET OR TAKE HOME INCOME NUMBER OF PEOPLE IN HOUSEHOLD DESCRIBE USE OF APPLICANT'S INCOME TOTAL FAMILY NET OR TAKE HOME INCOME $ Per $ Per PART E -- ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON FAMILY ENTERPRISE NAME AND ADDRESS OF ENTERPRISE NATURE AND TYPE OF ENTERPRISE YEARS IN BUSINESS NUMBER OF EMPLOYEES (INCLUDE FAMILY MEMBERS) EXPLAIN SPECIFICALLY WHY EACH EMPLOYEE CANNOT DO THE REQUESTED DRIVING. INCLUDE DAILY WORK AND TRAVEL SCHEDULE OF EACH EMPLOYEE California Relay Telephone Service for the deaf or hearing impaired from TDD Phones: 1-800-735-2929; from Voice Phones: 1-800-735-2922 DS 694 (REV. 2/2011) WWW American LegalNet, Inc. www.FormsWorkFlow.com EXPLAIN WHY SOMEONE CANNOT BE EMPLOYED TO DO THE REQUESTED DRIVING EXPLAIN WHY APPLICANT'S OPERATION OF A MOTOR VEHICLE IS NECESSARY TO THE ENTERPRISE HOURS PER WEEK APPLICANT WOULD WORK SALARY (IF ANY) AUTHORIZATION AND CERTIFICATION: (If under 18 years of age, both parents must sign) I/We hereby authorize the Department of Motor Vehicles to ask for and receive any additional information needed to determine eligibility for a critical need restriction from physician, school principal and/or employer certifying to a Statement of Facts. Medical information is confidential under Section 1808.5 VC. I/We certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. (Perjury is punishable by imprisonment or fine or both.) Both parents must sign unless one has custody and writes: "I have sole custody." APPLICANT'S SIGNATURE DATE ADDRESS CITY ZIP CODE X FATHER'S SIGNATURE DATE ADDRESS CITY ZIP CODE X MOTHER'S SIGNATURE DATE ADDRESS CITY ZIP CODE X SECTION 2 -- STATEMENT OF FACTS BY PHYSICIAN Physician must complete a separate statement for each family member whose disability affects driving or transportation needs NAME OF PATIENT DIAGNOSIS MEDICAL CONDITION(S) AND SYMPTOM(S) PROGNOSIS (INCLUDE PROBABLE DATE WHEN SUFFICENT RECOVERY WILL HAVE BEEN MADE TO TERMINATE THE EMERGENCY. IF CONDITION IS CHRONIC, PHYSCIAN MUST STATE THAT FACT) DOES PATIENT'S CONDITION RULE OUT DRIVING? YES NO DOES PATIENT'S CONDITION RULE OUT USE OF PUBLIC TRANSPORTATION? INCLUDING PARATRANSIT (CURB TO CURB SERVICE) Yes No SECTION 3 -- STATEMENT OF FACTS BY SCHOOL PRINCIPAL OR DEAN School principal or dean must complete if hardship condition is to and from school. If hardship condition is to and from college, submit a printout of current schedule, including days and hours of all classes in which enrolled. STUDENT'S NAME LENGTH OF ATTENDANCE STUDENT'S DAILY SCHOOL HOURS If yes, Permanently Temporary-low long? EXPLAIN WHY SCHOOL AND OTHER TRANSPORTATION IS INADEQUATE FOR REGULAR ATTENDANCE AT SCHOOL AND ACTIVITIES AUTHORIZED BY THE SCHOOL NAME AND ADDRESS OF SCHOOL NAME OF SCHOOL DISTRICT DISTANCE: RESIDENCE TO SCHOOL BUS STOP (if any) SCHOOL TO PUBLIC TRANSPORTATION LAST DAY OF STUDENT'S SCHOOL YEAR SECTION 4 -- STATEMENT OF FACTS
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