"Application for Nebraska Employment Driving Permit - Support" - Nebraska

Application for Nebraska Employment Driving Permit - Support is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

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Download "Application for Nebraska Employment Driving Permit - Support" - Nebraska

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DMV PROCEDURAL BULLETIN
EMPLOYMENT DRIVING PERMIT – SUPPORT ORDER VIOLATION
WHAT IS THE EMPLOYMENT DRIVE PERMIT?
The Employment Driving Permit is authorized by Nebraska State Statute 60-4,129, for driver’s who have forfeited their
regular driving privileges for non-payment of a support order.
This permit can be used to drive from home to work and return, and strictly in reference to the terms of employment. It
cannot be used for visitation, shopping, doctor’s appointment, probationary meetings, school (unless school is required and
subsidized by employer), etc.
The issuance of such permit is based upon meeting all appropriate requirements and certification that the use of the vehicle
is required as part of one’s employment and there is not reasonable alternative means of transportation.
WHO IS ELIGIBLE AND HOW LONG IS THE PERMIT VALID FOR?
ONLY THOSE INDIVIDUALS WHOSE DRIVING PRIVILEGES HAVE BEEN SUSPENDED FOR VIOLATION OF A
SUPPORT ORDER ARE ELIGIBLE. Any other suspension or revocation actions must be reinstated in order to be eligible
for an Employment Driving Permit. Driver must have tested for and been issued a driver license (in any state) prior to being
suspended in Nebraska. Driver can apply for the permit anytime during the suspension and can be issued only one permit
during the suspension period. The employment drive permit is valid for three months from the issuance date of the permit
and is not renewable.
WHAT ARE THE REQUIREMENTS?
(1) An Application For Nebraska Employment Driving Permit - Support (the application can be downloaded from the
Department of Motor Vehicles website
http://www.dmv.ne.gov
or can be mailed to the driver upon request. A separate
application must be completed for each place of employment.
(2) The application form will include: a) General application - driver must complete first two (2) pages in full; b) Employer’s
Affidavit - Employer must complete in full; c) Self-Employment Affidavit if the driver is self-employed this section must be
completed in full and submitted with documentation of self-employment - Schedule C or Schedule F, Form 1120 or
1120S income tax form (required if the business has filed income tax); if taxes have not been filed - letterhead
stationery, business card, etc.; and d) An affidavit certifying no alternative means of transportation.
The application form must be submitted for evaluation and review (the Department must meet all statutory
requirements in review and evaluation of the application) and the Department must be able to confirm
employment by telephone.
(3) The suspended Nebraska Operator’s License (if not already surrendered or expired).
(4) Proof of financial responsibility may be given by one of the following: a) By filing with the Department of Motor Vehicles,
a written certificate of insurance from any insurance company duly authorized to do business in the State of Nebraska,
certifying that there is in effect a motor vehicle liability policy for the benefit of the person required to furnish the proof of
financial responsibility. The certificate of insurance is identified by form SR-22. We are not permitted to accept your
policy or a binder as being the proper identification of your proof of financial responsibility. b) A Bond of a Surety
Company duly authorized to transact business within the State of Nebraska or a bond with at least two individual
sureties who each own real estate within the State of Nebraska which real estate shall be scheduled in the bond
approved by a Judge or a court of record. This said bond shall be conditioned for the payment of the amounts specified
in sub-section 10 in Section 60-501 ($75,000.00). c) A Cash bond in the amount of $75,000.00 furnished by a certified
check, bank draft, or money order.
THE DIRECTOR OF THE DEPARTMENT OF MOTOR VEHICLES WILL REVOKE THE EMPLOYMENT DRIVING PERMIT
OF ANY DRIVER CONVICTED OF A VIOLATION FOR WHICH POINTS ARE ASSESSED. If the permit is revoked in this
manner, the individual will not be eligible to receive an Employment Driving Permit for the remainder of the period of
suspension or revocation.
WHERE DO I APPLY AND HOW LONG WILL IT TAKE?
Send requirements to the Department of Motor Vehicles, Employment Driving Permit Program, P.O. Box 94877, Lincoln, NE
68509, (402) 471-3985. If requirements are met, the Employment Drive Permit Authorization letter will be issued for the
driver to present to the Driver License Examiner. Driver will need to pay the $47.50 fee to the County Treasurer for issuance
of the permit.
Printed with soy ink on recycled paper
REV 08/2009
DMV PROCEDURAL BULLETIN
EMPLOYMENT DRIVING PERMIT – SUPPORT ORDER VIOLATION
WHAT IS THE EMPLOYMENT DRIVE PERMIT?
The Employment Driving Permit is authorized by Nebraska State Statute 60-4,129, for driver’s who have forfeited their
regular driving privileges for non-payment of a support order.
This permit can be used to drive from home to work and return, and strictly in reference to the terms of employment. It
cannot be used for visitation, shopping, doctor’s appointment, probationary meetings, school (unless school is required and
subsidized by employer), etc.
The issuance of such permit is based upon meeting all appropriate requirements and certification that the use of the vehicle
is required as part of one’s employment and there is not reasonable alternative means of transportation.
WHO IS ELIGIBLE AND HOW LONG IS THE PERMIT VALID FOR?
ONLY THOSE INDIVIDUALS WHOSE DRIVING PRIVILEGES HAVE BEEN SUSPENDED FOR VIOLATION OF A
SUPPORT ORDER ARE ELIGIBLE. Any other suspension or revocation actions must be reinstated in order to be eligible
for an Employment Driving Permit. Driver must have tested for and been issued a driver license (in any state) prior to being
suspended in Nebraska. Driver can apply for the permit anytime during the suspension and can be issued only one permit
during the suspension period. The employment drive permit is valid for three months from the issuance date of the permit
and is not renewable.
WHAT ARE THE REQUIREMENTS?
(1) An Application For Nebraska Employment Driving Permit - Support (the application can be downloaded from the
Department of Motor Vehicles website
http://www.dmv.ne.gov
or can be mailed to the driver upon request. A separate
application must be completed for each place of employment.
(2) The application form will include: a) General application - driver must complete first two (2) pages in full; b) Employer’s
Affidavit - Employer must complete in full; c) Self-Employment Affidavit if the driver is self-employed this section must be
completed in full and submitted with documentation of self-employment - Schedule C or Schedule F, Form 1120 or
1120S income tax form (required if the business has filed income tax); if taxes have not been filed - letterhead
stationery, business card, etc.; and d) An affidavit certifying no alternative means of transportation.
The application form must be submitted for evaluation and review (the Department must meet all statutory
requirements in review and evaluation of the application) and the Department must be able to confirm
employment by telephone.
(3) The suspended Nebraska Operator’s License (if not already surrendered or expired).
(4) Proof of financial responsibility may be given by one of the following: a) By filing with the Department of Motor Vehicles,
a written certificate of insurance from any insurance company duly authorized to do business in the State of Nebraska,
certifying that there is in effect a motor vehicle liability policy for the benefit of the person required to furnish the proof of
financial responsibility. The certificate of insurance is identified by form SR-22. We are not permitted to accept your
policy or a binder as being the proper identification of your proof of financial responsibility. b) A Bond of a Surety
Company duly authorized to transact business within the State of Nebraska or a bond with at least two individual
sureties who each own real estate within the State of Nebraska which real estate shall be scheduled in the bond
approved by a Judge or a court of record. This said bond shall be conditioned for the payment of the amounts specified
in sub-section 10 in Section 60-501 ($75,000.00). c) A Cash bond in the amount of $75,000.00 furnished by a certified
check, bank draft, or money order.
THE DIRECTOR OF THE DEPARTMENT OF MOTOR VEHICLES WILL REVOKE THE EMPLOYMENT DRIVING PERMIT
OF ANY DRIVER CONVICTED OF A VIOLATION FOR WHICH POINTS ARE ASSESSED. If the permit is revoked in this
manner, the individual will not be eligible to receive an Employment Driving Permit for the remainder of the period of
suspension or revocation.
WHERE DO I APPLY AND HOW LONG WILL IT TAKE?
Send requirements to the Department of Motor Vehicles, Employment Driving Permit Program, P.O. Box 94877, Lincoln, NE
68509, (402) 471-3985. If requirements are met, the Employment Drive Permit Authorization letter will be issued for the
driver to present to the Driver License Examiner. Driver will need to pay the $47.50 fee to the County Treasurer for issuance
of the permit.
Printed with soy ink on recycled paper
REV 08/2009
Financial Responsibility Division
Employment Driving Permit Program
301 Centennial Mall South, P.O. Box 94877
Lincoln, Nebraska 68509-4877
(402) 471-3985 Fax (402) 471-8288
APPLICATION FOR NEBRASKA EMPLOYMENT DRIVING PERMIT – SUPPORT
Items A – E below must be completed and sent to the Financial Responsibility Division at the address
listed above. If the application is properly completed and you are eligible, you will be sent a letter
1
authorizing you to go to a Driver Examining Station to be issued the Employment Driving Permit.
A.
Must be a Nebraska resident, have tested and been issued a license (Provisional Operator’s Permit holders are not
eligible for the Employment Drive Permit).
B.
Current Nebraska Operator’s License – if not already surrendered;
C.
Properly completed SR-22 Certificate of Insurance from your insurance company (application, binder or insurance
card will not be accepted);
D.
This completed application form – including documentation of self-employment (if applicable). You will need a
separate application for each job you hold; and,
E.
Comply with all reinstatement requirements for any suspensions/revocations in Nebraska or any other state that
prohibits you from obtaining the Employment Drive Permit.
The Authorization Letter for Issuance of Employment Drive Permit is based upon you, the driver,
meeting all conditions and the Department being able to verbally confirm employment with your
NOTE:
employer. If any of the above requirements are not met, you will not be issued the Authorization
Letter.
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 Employment Drive Permit.
Authorization is based on meeting all conditions including certification that the use of a vehicle is a
requirement for employment and there is no reasonable alternative means of transportation.
By si g n i n g t h i s ap p li cat i o n I sw e a r o r af f i r m t h at :
I certify that I will notify the Department of Motor Vehicles of change or termination of employment. If
3
I change employment, I must immediately contact the Department of Motor Vehicles to file a revised
application in reference to my new employment in order to maintain my Employment Driving Permit
privileges. I understand that my permit will not be valid until there is a properly completed application
on file for my new job.
Please initial
By initialing this statement, I agree and understand that failure to notify the Department
of any change in my employment will cause my Employment Driving Permit to
immediately become null and void.
I understand that the Director of the Department of Motor Vehicles will revoke the Employment Drive
4
Permit upon receipt of the abstract of conviction indicating that I committed an offense for which points
are assessed and I will not be eligible to receive an Employment Driving Permit for the remainder of the
period of revocation or suspension of my operator’s license or privilege to drive.
Please initial
By initialing this statement, I understand that if I commit any violation where points are
assessed my Employment Driving Permit will be revoked.
Employment information. If you are self-employed – skip to Part 7:
5
Where do you work:
Your work phone number:
Describe what you do at your
job:
Routes/Areas of travel - detailed information is required for your protection. If you are
stopped driving after the permit has been issued, law enforcement will refer to the
6
application you submitted for verification of your Routes/Areas of travel. If you need
more space – please attach a separate sheet of paper.
Routes to and from work:
Routes for driving during work:
Bus Routes:
Other:
Briefly describe other transportation options available:
Yo u m u st si g n t h i s ap p li cat i o n i n t h e p r e se n ce o f a No t ar y Pu b li c:
State of
7
County of
Applicant’s Signature
The signature of the Applicant was acknowledged before me this
day of
,
.
Printed name
Notary Public Signature
Date:
Seal
Employers Affidavit (skip to next page if you are Self-Employed)
8
Your Employee is making application for a Nebraska Employment Drive Permit. State law requires, as one of the conditions for issuance
for such permit, that the employer sign an affidavit swearing to the validity of the claim that the use of a vehicle is required in traveling to
and from his or her place of employment and/or in the course of the applicant’s employment.
Your assistance is appreciated. It should be noted that the Department of Motor Vehicles will contact the Human Resource/Personnel
Office to verbally confirm employment and a false swearing jeopardizes all parties and the validity of the application. If permit is
authorized, you will be required to notify the Department of Motor Vehicles in writing of termination of employment of applicant.
Your Employee’s (Applicant’s) Name:
Street Address
City / State / Zip Code
Your Employee’s (Applicant’s) Address:
Business information
9
Business name (place of employment):
Street Address
City / State / Zip Code
Business Address:
Name
Phone Number
Employer’s Name / Phone number:
Name
Phone Number
HR / Personnel Contact / Phone number:
I can confirm the need for my employee to drive as a condition of his/her employment as
10
described below:
Please circle
1.
My employee is “only” required to drive to and from work.
Yes
No
My employee is required to drive to / from work and must also drive to meet employment
Please circle
2.
responsibilities (i.e. deliveries, between job sites, etc.).
Yes
No
Please circle
3.
The routes/areas of travel my employee listed in Section 6 are correct.
Yes
No
):
Days employee is required to work (please
days required
4.
(√)
(√)
(√)
(√)
(√)
(√)
(√)
MON
TUE
WED
THUR
FRI
SAT
SUN
Hours employee is required to work - up to a 12-hour work shift will be accepted, anything over 12 hours the DMV will consider as
overtime. Please include driving time:
Leave Home at:
am
pm
Work shift starts at:
am
pm
5.
Work shift ends at:
am
pm
Return home at:
am
pm
Overtime hours (anything over
a 12 hour shift) – please
describe:
I am aware that if the Employment Drive Permit is authorized for my employee, I will be required to
Please initial
6.
notify the Department of Motor Vehicles in writing if the employee quits or is terminated prior to the
expiration of the Employment Drive Permit.
You must sign the application in the presence of a Notary Public:
Signature below must be same as Employer’s Name provided in
Section 10 above.
State of
11
County of
Employer’s Signature
The signature of the Employer was acknowledged before me
this
Printed name
day of
,
.
Notary Public Signature
Seal
Date:
The Employment Drive Permit cannot be used to operate a commercial motor vehicle or
NOTE:
as a commercial driver’s license.
12
Self-Employment Affidavit (complete only if you are self-employed)
Being self-employed as described on the notarized application form, and being first duly sworn, I hereby certify
that my employment requires licensing as described below.
Company Information:
Name of your Company:
Date the Company or Business was established:
Please circle applicable
Have Income Taxes for this Company or Business been
filed yet:
Yes
No
Extension has been filed
Days/Hours – detailed information is required for your protection. If you are stopped
13
driving after the permit has been issued, law enforcement will refer to the application
you submitted for verification of the days/hours you work.
):
Days you are required to work (please
days required
(√)
(√)
(√)
(√)
(√)
(√)
(√)
MON
TUE
WED
THUR
FRI
SAT
SUN
Hours you are required to work - up to a 12-hour work shift will be accepted, anything over 12 hours the DMV will consider as overtime.
Please include driving time:
Leave home at:
am
pm
Work shift starts at:
am
pm
Work shift ends at:
am
pm
Return home at:
am
pm
Overtime hours (anything over a
12 hour shift) – please describe:
Describe your job:
If you have filed income taxes or an extension – you are required to submit
14
the applicable form listed below:
A Schedule C or Schedule F income tax form (or similar proof of current self-employment) is required if you
have an established business and have filed income taxes – you may need to consult with your Accountant to obtain
the correct schedule or form.
A 1120 or 1120S income tax form (or similar proof of current self-employment) – is required if your business is
incorporated and you have an established business that has filed income taxes - you may need to consult with your
Accountant to obtain the correct schedule or form.
A 4868 (sole proprietorship) or 7004 (S or C Corporations, Partnerships, etc.) (or similar proof of current self-
employment) is required if you have an established business, have not filed taxes but have filed for an extension to
pay income taxes. You may need to consult with your Accountant to obtain the correct schedule or form.
If you have not filed income taxes or an extension – you are required to submit
documentation from the following list:
1. Letterhead stationery, Business Card, Business Check
2. Tax Identification Number
3. Registration of Business Name with the Secretary of States Office
APPLICATION FOR EMPLOYMENT DRIVING PERMIT
REV 12/29/2011
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