"Application for Subsidy" - New Mexico

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NMDOT TRAFFIC SAFETY DIVISION (TSD)
7
INSTRUCTIONS FOR COMPLETING APPLICATION FOR SUBSIDY
IGNITION INTERLOCK INDIGENT DEVICE FUND * UNDER SEC. 66-8-102.3 & 66-2-7.1 NMSA 1978
P.O. BOX 1149; SANTA FE, NM 87504
*
(505) 827-0427 OR 1-800-541-7952
IF APPROVED, WHAT ARE THE IGNITION INTERLOCK DEVICE FUND BENEFITS?
If indigency is granted and provided that money is available in the Interlock Device Fund, the NMDOT Traffic Safety Bureau shall pay for one vehicle per
offender, up to: $50.00 for the cost of installation; $30.00 monthly for verified active usage of the interlock device, and up to $50.00 for the cost of removal. The
offender is responsible for all other charges associated with the installation, servicing and removal of the ignition interlock device. The interlock device fund fee
collected by MVD shall not be imposed on an indigent person.
WHO QUALIFIES FOR BENEFITS FROM THE IGNITION INTERLOCK INDIGENT DEVICE FUND?
Individuals who are required, pursuant to convictions under Section 66-8-102 NMSA 1978 or adjudications on the basis of 32A-2-3 NMSA 1978 or NM driver's license
revocations pursuant to the Provisions of the Implied Consent Act or as a Condition of Parole, to drive interlocked.
If applicant has been convicted in New Mexico for Driving While Intoxicated (DWI) and have been court ordered to a period of interlock.
If driver's license is revoked by the Motor Vehicle Division because of a DWI arrest and you can not drive legally without an Ignition Interlock.
If applicant has been ordered to drive interlocked as a condition of parole.
HOW DOES APPLICANT APPLY FOR ASSISTANCE?
Complete and submit the NMDOT Traffic Safety Division Application For Subsidy and provide proof of enrollment document (see below)
Incomplete applications will be returned to applicant. Also, TSD will not accept faxed or emailed applications. See below for address information.
STEP 1
- INSTRUCTIONS
STEP 2
- INSTRUCTIONS
INITIAL - FIRST TIME APPLICANT
RECERTIFICATION - SECOND OR SUBSEQUENT APPLICANT
If recertifying indigent status which means applicant was previously approved based
If a first time applicant, complete and submit the NMDOT Traffic Safety Division
on an application submitted less than one year ago, then applicant will not need to fill
Application For Subsidy. Have signature on application notarized by a notary
out a new application. Applicant will instead submit a copy of the current proof of
public and attach relevant documents as required to avoid benefit denial or delays.
enrollment document (see below). If the approved application on file with TSD is over
If benefits are approved, the application will stay on file for 1 year. If need to
1 year, a new application will be required. If unsure, call TSD to determine if new
extend benefits after initial approval, see STEP 2.
application is needed.
WHAT ASSISTANCE DOCUMENT MUST BE PROVIDED WITH APPLICATION?
Indigency shall be determined by the Traffic Safety Division based on applicant's proof of enrollment in one or more of the public assistance programs.
Applicaton will be denied if current proof of enrollment document is not provided.
PUBLIC ASSISTANCE PROGRAMS:
PROOF OF ENROLLMENT DOCUMENT:
TANF -
Temporary Assistance for Needy Families
Notice of Approved Case Action, Form # ISDB003 or other benefit verification from
GA -
General Assistance
Income Support Division
Supplemental Nutritional Assistance Program (Food Stamps)
SNAP -
Benefit Verification Letter from the Social Security Office
SSI -
Supplemental Security Income
Note: SSI is not Social Security Disability
FDPIR -
Food Distribution Program on Indian Reservations
TSD (FDPIR) Verification Form from FDPIR office
Valid Indigency Order from a NM Court, Probation or Parole dated prior to July 1,
Indigency Determination prior to 2010 from a NM Court, Probation
2010. Applicant must also complete the NMDOT Traffic Safety Division Application
or Parole specifically for Ignition Interlock Purposes if relates to current
OI -
for Subsidy. A valid indigency order must have client's name, be signed and dated by
license revocation
Judge, Probation or Parole and indicate indigency is for Ignition Interlock.
WHERE DOES APPLICANT SEND COMPLETED APPLICATION?
MAILING ▼
DROPPING OFF ▼
Web Link to Application and Instruction Page
http://dot.state.nm.us
The office that serves all areas is located at:
Traffic Safety Division Ignition Interlock Fund
P.O. Box 1149
1122 Cerrillos Road (SB1-N)
Select Traffic Safety under News & Information
Santa Fe, NM 87504
(505) 827-0427 or 1-800-541-7952
Santa Fe, NM 87505
HOW WILL APPLICANT KNOW IF THEY WERE APPROVED FOR BENEFITS?
TSD will send a notice to the mailing address listed on application that informs applicant if indigency was approved, or if application was denied or was incomplete
IF APPROVED
IF DENIED OR INCOMPLETE
If incomplete, the notice will list the reason(s) application is incomplete. If
The notice will indicate benefit effective dates. Eligibility for subsidy
information is requested by TSD the notice will identify what is missing.
benefits will only apply during effective dates listed on letter.
Once obtained applicant may resubmit for consideration.
TSD will notify MVD of the indigency status. As long as applicant obtains
an ignition interlock license between the effective dates, MVD will not
If denied, the letter will list the reason(s) for denial. Applicant may reapply if
charge the interlock device fund fee.
later meets the statutory requirements.
Applicant will provide a copy of the notice to the Interlock Provider to
obtain the eligible approved benefits. Applicant tracks indigency effective
dates on notice as it is the applicant's responsibility to reapply in a timely
manner so there is not a lapse in coverage.
NMDOT TRAFFIC SAFETY DIVISION (TSD)
7
INSTRUCTIONS FOR COMPLETING APPLICATION FOR SUBSIDY
IGNITION INTERLOCK INDIGENT DEVICE FUND * UNDER SEC. 66-8-102.3 & 66-2-7.1 NMSA 1978
P.O. BOX 1149; SANTA FE, NM 87504
*
(505) 827-0427 OR 1-800-541-7952
IF APPROVED, WHAT ARE THE IGNITION INTERLOCK DEVICE FUND BENEFITS?
If indigency is granted and provided that money is available in the Interlock Device Fund, the NMDOT Traffic Safety Bureau shall pay for one vehicle per
offender, up to: $50.00 for the cost of installation; $30.00 monthly for verified active usage of the interlock device, and up to $50.00 for the cost of removal. The
offender is responsible for all other charges associated with the installation, servicing and removal of the ignition interlock device. The interlock device fund fee
collected by MVD shall not be imposed on an indigent person.
WHO QUALIFIES FOR BENEFITS FROM THE IGNITION INTERLOCK INDIGENT DEVICE FUND?
Individuals who are required, pursuant to convictions under Section 66-8-102 NMSA 1978 or adjudications on the basis of 32A-2-3 NMSA 1978 or NM driver's license
revocations pursuant to the Provisions of the Implied Consent Act or as a Condition of Parole, to drive interlocked.
If applicant has been convicted in New Mexico for Driving While Intoxicated (DWI) and have been court ordered to a period of interlock.
If driver's license is revoked by the Motor Vehicle Division because of a DWI arrest and you can not drive legally without an Ignition Interlock.
If applicant has been ordered to drive interlocked as a condition of parole.
HOW DOES APPLICANT APPLY FOR ASSISTANCE?
Complete and submit the NMDOT Traffic Safety Division Application For Subsidy and provide proof of enrollment document (see below)
Incomplete applications will be returned to applicant. Also, TSD will not accept faxed or emailed applications. See below for address information.
STEP 1
- INSTRUCTIONS
STEP 2
- INSTRUCTIONS
INITIAL - FIRST TIME APPLICANT
RECERTIFICATION - SECOND OR SUBSEQUENT APPLICANT
If recertifying indigent status which means applicant was previously approved based
If a first time applicant, complete and submit the NMDOT Traffic Safety Division
on an application submitted less than one year ago, then applicant will not need to fill
Application For Subsidy. Have signature on application notarized by a notary
out a new application. Applicant will instead submit a copy of the current proof of
public and attach relevant documents as required to avoid benefit denial or delays.
enrollment document (see below). If the approved application on file with TSD is over
If benefits are approved, the application will stay on file for 1 year. If need to
1 year, a new application will be required. If unsure, call TSD to determine if new
extend benefits after initial approval, see STEP 2.
application is needed.
WHAT ASSISTANCE DOCUMENT MUST BE PROVIDED WITH APPLICATION?
Indigency shall be determined by the Traffic Safety Division based on applicant's proof of enrollment in one or more of the public assistance programs.
Applicaton will be denied if current proof of enrollment document is not provided.
PUBLIC ASSISTANCE PROGRAMS:
PROOF OF ENROLLMENT DOCUMENT:
TANF -
Temporary Assistance for Needy Families
Notice of Approved Case Action, Form # ISDB003 or other benefit verification from
GA -
General Assistance
Income Support Division
Supplemental Nutritional Assistance Program (Food Stamps)
SNAP -
Benefit Verification Letter from the Social Security Office
SSI -
Supplemental Security Income
Note: SSI is not Social Security Disability
FDPIR -
Food Distribution Program on Indian Reservations
TSD (FDPIR) Verification Form from FDPIR office
Valid Indigency Order from a NM Court, Probation or Parole dated prior to July 1,
Indigency Determination prior to 2010 from a NM Court, Probation
2010. Applicant must also complete the NMDOT Traffic Safety Division Application
or Parole specifically for Ignition Interlock Purposes if relates to current
OI -
for Subsidy. A valid indigency order must have client's name, be signed and dated by
license revocation
Judge, Probation or Parole and indicate indigency is for Ignition Interlock.
WHERE DOES APPLICANT SEND COMPLETED APPLICATION?
MAILING ▼
DROPPING OFF ▼
Web Link to Application and Instruction Page
http://dot.state.nm.us
The office that serves all areas is located at:
Traffic Safety Division Ignition Interlock Fund
P.O. Box 1149
1122 Cerrillos Road (SB1-N)
Select Traffic Safety under News & Information
Santa Fe, NM 87504
(505) 827-0427 or 1-800-541-7952
Santa Fe, NM 87505
HOW WILL APPLICANT KNOW IF THEY WERE APPROVED FOR BENEFITS?
TSD will send a notice to the mailing address listed on application that informs applicant if indigency was approved, or if application was denied or was incomplete
IF APPROVED
IF DENIED OR INCOMPLETE
If incomplete, the notice will list the reason(s) application is incomplete. If
The notice will indicate benefit effective dates. Eligibility for subsidy
information is requested by TSD the notice will identify what is missing.
benefits will only apply during effective dates listed on letter.
Once obtained applicant may resubmit for consideration.
TSD will notify MVD of the indigency status. As long as applicant obtains
an ignition interlock license between the effective dates, MVD will not
If denied, the letter will list the reason(s) for denial. Applicant may reapply if
charge the interlock device fund fee.
later meets the statutory requirements.
Applicant will provide a copy of the notice to the Interlock Provider to
obtain the eligible approved benefits. Applicant tracks indigency effective
dates on notice as it is the applicant's responsibility to reapply in a timely
manner so there is not a lapse in coverage.
TSD USE ONLY
Date Stamp
Rev 03.21.17
Refund:
LAST VALID APPL DATE:
No.
PREV IIDF APVL DATES:
No.
Apvd By:
From:
MVD REVOCATION PERIOD:
J&S
INTERLOCK LICENSE DATES:
Amt PD:
To:
A
D
I
TANF - GA - SNAP - SS I - FDPIR - OI
PUBLIC ASST TYPE:
No.
PUBLIC ASST DATES:
Verified with:
PREV ASST TYPE/APVL DATES:
Filed w/No.
NMDOT TRAFFIC SAFETY DIVISION (TSD)
APPLICATION FOR SUBSIDY
IGNITION INTERLOCK INDIGENT DEVICE FUND * UNDER SEC. 66-8-102.3 & 66-2-7.1 NMSA 1978
P.O. BOX 1149 * SANTA FE, NM 87504
*
(505) 827-0427 OR 1-800-541-7952
PART A:
APPLICANT INFORMATION
Please print clearly or type / all items each section must be completed
Applicant Full Name (First, MI, Last, Suffix (i.e., Jr., Sr.)
Date of Birth
Social Security Number
(1)
(2)
(3)
Driver License Number or State ID Number
Issuing State
Primary Telephone Number:
(4)
(5)
(6)
(
)
Mailing Address
(8) Secondary Telephone Number
(7)
(
)
(9) City
(10) State
(11) Zip Code
PART B:
INDICATE IF DRIVER LICENSE HAS BEEN REVOKED AND IF REQUIRED TO BE INTERLOCKED BY PAROLE
Date of Court Conviction:
Date of MVD Revocation:
(13)
(12)
Court Name:
) Court City
Court Case Number
(14)
(15
(16)
JUDGEMENT & SENTENCE
ATTACH A COPY OF THE
(J&S) FROM THE SENTENCING COURT FOR CURRENT DUI CONVICTION
Have you been ordered as a condition of parole to drive with an interlock?
Yes
No
(17)
CERTIFICATE OF PAROLE
ATTACH A COPY OF THE
IF REQUIRED TO BE INTERLOCKED AS A CONDITION OF PAROLE
PART C:
INDICATE QUALIFYING PUBLIC ASSISTANCE PROGRAM(S) AND SPECIFY ELIGIBILITY DATES
TANF
GA
SNAP
SSI
(Supplemental Security Income)
FDPIR
(18)
Eligibility From Date:
Eligibility To Date:
(19)
(20)
PROOF OF ENROLLMENT
MUST ATTACH
IN ONE OF THE QUALIFYING PUBLIC ASSISTANCE PROGRAM(S)
PART D:
INDICATE IF A COURT, PROBATION OR PAROLE DETERMINED CLIENT INDIGENT FOR INTERLOCK
INDIGENT BY A NM COURT, PROBATION OR PAROLE
PRIOR TO 7/1/2010
FOR INTERLOCK PURPOSES
(21)
Case # on Court Order:
Date on Court Order:
(22)
(23)
COURT ORDER
MUST ATTACH A COPY OF THE
SPECIFYING INDIGENCY, IF DETERMINED INDIGENT PRIOR TO 7/1/10
PART E:
INDICATE WHETHER THE IGNITION INTERLOCK DEVICE IS CURRENTLY INSTALLED IN VEHICLE(S)?
Date Interlock Installed:
Ignition Interlock Company Name / City:
(24)
(25)
PART F:
AGREEMENT, SIGNATURE AND NOTARIZATION
I understand that false and misleading information in this application can be the basis for denial of this Application.
If this Application is approved, I understand that I must install and maintain the ignition interlock device according to Sec. 66-5-503 NMSA 2003 ignition interlock
license requirements and Sec. 66-8-102.3 NMSA 2010 Interlock Device Fund. The Division may consider any deviation to be a breach of the agreement which could
result in revocation of assistance from the Interlock Device Fund.
I agree to notify the Division within ten (10) business days of any change to any information in this application.
By signing this form, I hereby acknowledge acceptance and understanding of the above statements. Additionally, I certify under penalties of perjury that all
information in this Application is true, correct and complete to the best of my knowledge and belief.
NOTARIAL
SEAL
(26)
(27)
Applicant Signature
Date
Applicant signature must be notarized or application will not be considered
The foregoing instrument was acknowledged before me this _____ day of ___________ 20______ by ____________________.
Notary - PRINT NAME
Notary Public Signature
My Commission Expires: _______________________
Instructions for completing this application and indigent benefits are on the back of this document or on a separate page depending on printing options
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