"Nebraska Department of Motor Vehicles Affidavit Annual Indigent Interlock Fee Payment Application" - Nebraska

Nebraska Department of Motor Vehicles Affidavit Annual Indigent Interlock Fee Payment Application is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

Form Details:

  • Released on June 1, 2020;
  • The latest edition currently provided by the Nebraska Department of Motor Vehicles;
  • Ready to use and print;
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  • 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 "Nebraska Department of Motor Vehicles Affidavit Annual Indigent Interlock Fee Payment Application" - Nebraska

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NEBRASKA DEPARTMENT OF MOTOR VEHICLES AFFIDAVIT ANNUAL
INDIGENT INTERLOCK FEE PAYMENT APPLICATION
Return completed affidavit and any required attachments to the Department of Motor Vehicles, PO Box 94877, Lincoln NE
68509 4877 or fax to (402) 471-8288. This affidavit must be completed in full, notarized, and be submitted with supporting
documentation to be reviewed.
PERSONAL INFORMATION (PRINT OR TYPE):
NAME:
CONTACT PHONE:
STREET:
DATE OF BIRTH:
CITY/STATE/ZIP:
SOCIAL SEC. #
CHARGE(S): Provide the Arrest Date(s) for the Alcohol Violation:
Are you on Probation:
No
Yes, if Yes – who is your Probation Officer:
ADDITIONAL BENEFITS:
Check (√) any benefits you and/or any household member are receiving and attach proof (do not send originals). We
cannot process your application without proof and cannot return attachments.
General assistance
$
Unemployment benefits
$
Poverty-related veteran’s benefits
$
Other (explain):
$
HOUSEHOLD AND GROSS INCOME INFORMATION:
Please list yourself and everyone else living at this address (even if not related to you). List the income and/or
benefits for each person listed and how often the person is paid/or benefits received.
Gross Income and How Often it was received
Earnings from
Social Security
work before
(Supplemental
Food
Check if
deductions:
Medicaid
or Disability)
Stamps/SNAP
NO
Legal Name
income:
Income
How Often
Income
How Often
Income
How Often
Income
How Often
(First, Middle, Last)
Age
NOTICE: You are required to submit verification of Gross Income which includes the following: The three (3) most recent
pay stubs reflecting current wages, the most recent W2 and the most recent Tax Return or a Written Statement from
Employer. You must submit verification of Medicaid, Social Security and SNAP benefits.
OTHER MONTHLY INCOME:
$
Alimony
$
Interest, dividends, pensions, annuities
$
Stocks, bonds, certificates of deposit
LIQUID ASSETS:
$
Cash, savings, bank accounts, including joint accounts
$
Stocks, bonds, certificates of deposit
Equity in real estate
$
VEHICLE INFORMATION:
Year:
Model:
VIN:
Year:
Model:
VIN:
Page 1 of 2
NEBRASKA DEPARTMENT OF MOTOR VEHICLES AFFIDAVIT ANNUAL
INDIGENT INTERLOCK FEE PAYMENT APPLICATION
Return completed affidavit and any required attachments to the Department of Motor Vehicles, PO Box 94877, Lincoln NE
68509 4877 or fax to (402) 471-8288. This affidavit must be completed in full, notarized, and be submitted with supporting
documentation to be reviewed.
PERSONAL INFORMATION (PRINT OR TYPE):
NAME:
CONTACT PHONE:
STREET:
DATE OF BIRTH:
CITY/STATE/ZIP:
SOCIAL SEC. #
CHARGE(S): Provide the Arrest Date(s) for the Alcohol Violation:
Are you on Probation:
No
Yes, if Yes – who is your Probation Officer:
ADDITIONAL BENEFITS:
Check (√) any benefits you and/or any household member are receiving and attach proof (do not send originals). We
cannot process your application without proof and cannot return attachments.
General assistance
$
Unemployment benefits
$
Poverty-related veteran’s benefits
$
Other (explain):
$
HOUSEHOLD AND GROSS INCOME INFORMATION:
Please list yourself and everyone else living at this address (even if not related to you). List the income and/or
benefits for each person listed and how often the person is paid/or benefits received.
Gross Income and How Often it was received
Earnings from
Social Security
work before
(Supplemental
Food
Check if
deductions:
Medicaid
or Disability)
Stamps/SNAP
NO
Legal Name
income:
Income
How Often
Income
How Often
Income
How Often
Income
How Often
(First, Middle, Last)
Age
NOTICE: You are required to submit verification of Gross Income which includes the following: The three (3) most recent
pay stubs reflecting current wages, the most recent W2 and the most recent Tax Return or a Written Statement from
Employer. You must submit verification of Medicaid, Social Security and SNAP benefits.
OTHER MONTHLY INCOME:
$
Alimony
$
Interest, dividends, pensions, annuities
$
Stocks, bonds, certificates of deposit
LIQUID ASSETS:
$
Cash, savings, bank accounts, including joint accounts
$
Stocks, bonds, certificates of deposit
Equity in real estate
$
VEHICLE INFORMATION:
Year:
Model:
VIN:
Year:
Model:
VIN:
Page 1 of 2
COVID 19:
If you (or anyone else in your household) are unemployed due to COVID 19, you are required to include a letter
from the Employer documenting the layoff. The letter from Employer must include the name of the employer and
their contact information, the date of separation or furloughed date and if furloughed – possible time to return to
work.
If this is a temporary layoff – you will need to resubmit a new application when returning to work to determine if
indigent funding is still applicable.
TERMS OF INDIGENT ASSISTANCE:
If approved for assistance, funding will cover one (1) installation and one (1) removal for the duration of the
revocation period. It will also cover monthly monitoring fees for one (1) year from the date funding is approved.
Funding is dependent on having the ignition interlock permit issued. If you do not have the permit issued within 15
days, the indigent funding will be terminated.
By signing this Affidavit I swear or affirm that:
I certify that I am aware that the funding will cover one (1) installation and one (1) removal for the duration of the
revocation period. It will also cover monthly monitoring fees for one (1) year from the date funding is approved.
Funding is dependent on having the ignition interlock permit issued. If you do not have the permit issued within 15
days, the indigent funding will be terminated.
Please initial
By initialing this statement, I agree and understand that funding is only valid for one (1) year and that I
must have the permit issued within 15 days or funding will be terminated. Cost for the permit is $49.50
and is paid at time of issuance to the County Treasurer (not covered by Indigent Assistance).
I certify that I will notify the Department of Motor Vehicles of change of income status. If there are any changes, I
must immediately submit a revised Affidavit and supporting documentation of these changes.
Please initial
By initialing this statement, I agree and understand that failure to provide change of income status will
result in the indigent funding being terminated.
I certify under penalty of perjury under the laws of the State of Nebraska that the foregoing is true and correct. If at
any time the Department Of Motor Vehicles discovers that information in this affidavit was false, misleading,
inaccurate, or incomplete at the time the affidavit was submitted, the Department of Motor Vehicles will terminate
the Indigent Funding and may require me to pay for any costs or fees that were previously paid.
Date:
Signature:
County of
State of
The signature of the Applicant was acknowledged before me this ______________ day of ___________________, ______________.
SEAL:
NOTARY PUBLIC SIGNATURE:
DO NOT FILL OUT THIS PART - FOR DEPARTMENT USE ONLY:
Total Number in Household:
Gross annual Income:
Approved through:
Denied
By
PAGE 2 OF 2
REV 06/2020
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