"Application for Nebraska Ignition Interlock Permit (Iip)" - Nebraska

Application for Nebraska Ignition Interlock Permit (Iip) is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

Form Details:

  • Released on April 1, 2020;
  • The latest edition currently provided by the Nebraska Department of Motor Vehicles;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Motor Vehicles.

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Download "Application for Nebraska Ignition Interlock Permit (Iip)" - Nebraska

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Financial Responsibility Division
Ignition Interlock Permit Program
301 Centennial Mall South, P.O. Box 94877
Lincoln, Nebraska 68509-4877
(402) 471-3985 Fax: (402) 471-8288
APPLICATION FOR NEBRASKA IGNITION INTERLOCK PERMIT (IIP)
1
Items A – E below must be completed and sent to the Financial Responsibility Division (address listed above).
A.
You must be a current Nebraska resident and have been issued a license from any state.
B.
Comply with all reinstatement requirements for any suspensions/revocations in Nebraska or any other state before the
IIP may be issued;
C.
Submit this completed application form;
D.
Submit a current certificate of installation showing an approved device has been installed for each vehicle you will be
driving (An IIP cannot be used for operation of a Commercial Motor Vehicle); and,
E.
Include current Nebraska Operator’s License – if not already surrendered.
Provide Personal Information (Please Print)
2
nd
rd
Last Name
First Name
Middle Initial
Suffix (Jr., Sr., 2
, 3
)
Current Residential Address (Cannot accept a mailing address or P.O. Box)
City
State
Zip Code
Date of Birth
Home Phone Number
Social Security Number
Month
Day
Year
Providing you are eligible, upon receipt of all applicable requirements, you will be sent a letter authorizing
you to appear before a Driver License Examiner to obtain the Nebraska Ignition Interlock Permit.
By signing this application I swear or affirm that:
I understand that my license will be administratively revoked for the applicable period based on my record:
3
Six (6) months for a first offense for failure of an alcohol test – IIP available immediately; or,
One (1) year for a subsequent offense for failure of an alcohol test – IIP available after 45 days no driving; or,
One (1) year for refusal of an alcohol or drug test – IIP available after 90 days no driving.
Please initial
By initialing this statement, I agree and understand that my license will be revoked for the
applicable time frame as described above.
I understand that submitting this application for an IIP waives my right to contest the administrative revocation.
4
Please initial
By initialing this statement, I agree and understand that I cannot contest the administrative
revocation of my driver license.
I understand that I am required to have the IIP issued for legal operation of a motor vehicle (excluding
5
commercial motor vehicle) equipped with an ignition interlock device for the period of the revocation. If
convicted for any violation of the IIP, six (6) months will be added to the original revocation period.
Please initial
By initialing this statement, I understand that I cannot operate a motor vehicle until the IIP is
issued and can only operate a motor vehicle equipped with an Ignition Interlock device installed
and if I am convicted of any IIP violation(s), my revocation period will be extended for six (6)
months.
You must sign this application:
6
Applicant’s Signature
Date
REV 04/2020
Financial Responsibility Division
Ignition Interlock Permit Program
301 Centennial Mall South, P.O. Box 94877
Lincoln, Nebraska 68509-4877
(402) 471-3985 Fax: (402) 471-8288
APPLICATION FOR NEBRASKA IGNITION INTERLOCK PERMIT (IIP)
1
Items A – E below must be completed and sent to the Financial Responsibility Division (address listed above).
A.
You must be a current Nebraska resident and have been issued a license from any state.
B.
Comply with all reinstatement requirements for any suspensions/revocations in Nebraska or any other state before the
IIP may be issued;
C.
Submit this completed application form;
D.
Submit a current certificate of installation showing an approved device has been installed for each vehicle you will be
driving (An IIP cannot be used for operation of a Commercial Motor Vehicle); and,
E.
Include current Nebraska Operator’s License – if not already surrendered.
Provide Personal Information (Please Print)
2
nd
rd
Last Name
First Name
Middle Initial
Suffix (Jr., Sr., 2
, 3
)
Current Residential Address (Cannot accept a mailing address or P.O. Box)
City
State
Zip Code
Date of Birth
Home Phone Number
Social Security Number
Month
Day
Year
Providing you are eligible, upon receipt of all applicable requirements, you will be sent a letter authorizing
you to appear before a Driver License Examiner to obtain the Nebraska Ignition Interlock Permit.
By signing this application I swear or affirm that:
I understand that my license will be administratively revoked for the applicable period based on my record:
3
Six (6) months for a first offense for failure of an alcohol test – IIP available immediately; or,
One (1) year for a subsequent offense for failure of an alcohol test – IIP available after 45 days no driving; or,
One (1) year for refusal of an alcohol or drug test – IIP available after 90 days no driving.
Please initial
By initialing this statement, I agree and understand that my license will be revoked for the
applicable time frame as described above.
I understand that submitting this application for an IIP waives my right to contest the administrative revocation.
4
Please initial
By initialing this statement, I agree and understand that I cannot contest the administrative
revocation of my driver license.
I understand that I am required to have the IIP issued for legal operation of a motor vehicle (excluding
5
commercial motor vehicle) equipped with an ignition interlock device for the period of the revocation. If
convicted for any violation of the IIP, six (6) months will be added to the original revocation period.
Please initial
By initialing this statement, I understand that I cannot operate a motor vehicle until the IIP is
issued and can only operate a motor vehicle equipped with an Ignition Interlock device installed
and if I am convicted of any IIP violation(s), my revocation period will be extended for six (6)
months.
You must sign this application:
6
Applicant’s Signature
Date
REV 04/2020