Free 28622.pdf - Indiana

REQUEST FOR WAIVER
State Form 28622 (R3 / 5-01)

LEARNER PERMIT IS REQUIRED WHEN ISSUING WAIVER FOR OPERATOR'S LICENSE
*Branch personnel must complete.
Name Age

Mail completed form to: Bureau of Motor Vehicles (BMV) Driver Services 100 N. Senate Ave Room N405, IGCN Indianapolis, IN 46204

Date of birth (month, day, year) Social Security number

Address (street number, city and state)

ZIP code

Telephone number

Driver's license number

*Date learner permit issued (month, day, year)

*Branch location and number Relationship

Person signing financial responsibility slip if applicant is under 18 years old

Name

REQUIREMENTS FOR OBTAINING WAIVER In accordance with IC 9-24-3-3 or 9-24-4-2(b) the Commissioner is authorized to waive up to six (6) months of the age and experience requirements for an individual making application for an individual's initial operator's or chauffeur's license due to HARDSHIP conditions. IF THE INDIVIDUAL REQUESTING THE WAIVER IS UNDER EIGHTEEN (18) YEARS OF AGE: 1. The individual should be the only driver in their household and/or the primary means of support for their family unit. 2. The license should contribute directly to the welfare of the household. 3. There should be no other means of transportation readily available. 4. No one under the age of sixteen (16) will be granted a waiver without "proof of completion of an approved driver education course." IF THE INDIVIDUAL REQUESTING THE WAIVER IS OVER EIGHTEEN (18) YEARS OF AGE: 1. The individual should have no other readily accessible transportation available for gainful employment. 2. There should be no other means of transportation readily available. IF THE INDIVIDUAL REQUESTING THE WAIVER IS UNDER SIXTEEN (16) YEARS AND SIX (6) MONTHS OLD AND HAS COMPLETED DRIVER'S ED OUT OF STATE: 1. The individual must produce the out-of-state Drivers Education Certificate. PROCEDURES FOR OBTAINING A WAIVER 1. 2. 3. 4. The applicant for a waiver shall submit a Request for Waiver form to the Commissioner. The completed application will be reviewed and investigated by the Driver Services Division. If approved, the applicant will receive a written waiver on a form designated and signed by the Commissioner. The waiver may be presented upon approval to any branch of the Bureau of Motor Vehicles at the time of application for an initial Indiana operator's or chauffeur's license. 5. This waiver does not effect any requirement as to the written, vision and driving test. THE COMMISSIONER, WITHIN HIS DISCRETION, MAY ALTER ANY OF THE FOREGOING PROCEDURES WHEN IN HIS OPINION AN EXTREME EMERGENCY EXISTS. REQUIRED INFORMATION (MUST BE COMPLETED IN ITS ENTIRETY)
Have you ever had a driver license or permit in Indiana or any other state or country?

Yes

No

If Yes, when and where? Place and location, (city) of employment Working hours _________ to PM _________ AM PM _________ to AM _________ If Yes, when and where? (D.E. Cert may be required)

How many individuals in your household presently hold a valid license? Did you complete Drivers Education?

Yes

No

Is public transportation available in your area?

State your reason for requesting a waiver (Evidence / documentation of hardship circumstances may be required)

Under penalties of perjury, I hereby swear or affirm that the above statements are true to the best of my knowledge.
Signature of applicant Date signed (month, day, year)

FOR BMV USE ONLY
Recommendations

Driver Services Supervisor Approved Denied

Date signed (month, day, year)