Free 50190.FH11 - Indiana

REQUEST FOR SPECIAL / COURTESY TEST AFFIDAVIT
State Form 50190 (R / 12-04)

County

Date (month, day, year)

, State of Indiana
Name of driver

Address (number and street)

City

State

ZIP code

Telephone number

Date of birth (month, day, year)

(

)
Date of expiration (month, day, year)

Drivers license number

I am requesting a special / courtesy drive test to be administered to the above named driver for the following reason: (check one) Voluntary Rehab / Physician Low vision / Bioptic Complaint Documentation attached

I am requesting a Medical Review to be done on the above named driver for the following reason: Documentation attached

I swear or affirm that the information I have entered on this form is correct. I understand that making a false statement on this form may constitute the crime of perjury.
Signature of person requesting test (if other than driver) Date (month, day, year)

FOR INTERNAL USE ONLY: Written test required?

Yes

No

(Attach copy of score sheet)

I understand that failure of the Special / Courtesy test, could result in my license being invalidated for up to one (1) year.
Signature of driver being tested Date (month, day, year)

Continued on reverse side

INFORMATION BELOW IS TO BE FILLED OUT AND SIGNED BY A DRIVER EXAMINER / SUPERVISOR
Written test results:

Test 1 Test 2 Test 3
Drive test number

Passed Passed Passed

Failed Failed Failed

Verbal? Verbal? Verbal?

Yes Yes Yes Passed

No No No Failed (Attach copy of DT-1)

Drive test results

License issued

If new restrictions were added please list:

Yes

No COMMENTS

I the undersigned examiner depose and say upon my oath, that I administered a thorough drive test to the above named individual. I swear or affirm that the information I have entered on this and the DT-1 form is correct. I understand making a false statement on these forms may constitute the crime of perjury.
Signature of driver examiner / supervisor District number Date (month, day, year)