Ignition Interlock Device Financial Assistance Application - Washington State Department Of Licensing
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Ignition Interlock Device
Financial Assistance Application
If you are indigent and the Department of Licensing has required you to get an ignition interlock device, you can use this
form to apply for assistance with the costs of installation, removal, and leasing of the device.
We will notify you in writing if your application has been approved or denied. If you are denied, you may reapply in six
months. Send this completed application and ALL required attachments to:
Driver Records
Department of Licensing
PO Box 9030
Olympia WA 98507
Fax: (360) 570-7824
PRINT OR TYPE Name of applicant (Last, First, Middle initial)
Washington driver license number
Date of birth
(Area code) Daytime telephone number
Email
Eligibility information
1. Total number of persons in your household (include self) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If under age 21, does applicant live with parents? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If “Yes,” state name of parent(s) with whom juvenile resides and answer questions below for parent(s).
2. Monthly Income – Submit proof of monthly income, such as last 2 month’s pay stubs, copy of a
recent federal tax return, or W-2s. Applications will be denied if proof of income is not attached.
If you have no income or do not have proof of income, submit a signed written statement explaining
this. Attachments will not be returned.
a. Self and spouse’s monthly take-home pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
b. Contribution from any family member or other person with whom applicant lives
and who is helping to defray applicant’s basic living costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
c. Interest, dividends, or other income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
d. Pensions, annuities, social security and /or public assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
3. Monthly Expenses
a. Basic living costs (average monthly amount spent by applicant for shelter, food, utilities, health
care, transportation, clothing, loan payments, support payments, and court-imposed obligations) $
b. Other unusual expenses, including bail obligations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
4. Liquid Assets
a. Cash, savings, bank accounts, including joint accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
b. Stocks, bonds, certificates of deposit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
c. Equity in real estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
d. Equity in motor vehicle necessary to maintain employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
e. Equity in additional motor vehicles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
Additional benefits
Check any benefits you are receiving and attach proof. Applications will be denied if proof of benefits are not
attached. Attachments will not be returned.
Temporary assistance for needy families
General assistance
Poverty-related veteran’s benefits
Food stamps
Refugee resettlement benefits
Medicaid
Supplemental security income
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct .
X
Print the completed form and sign here.
Date and place signed
Signature
For Department Use Only
RCW 10.101.010
Approved
Denied By
We are committed to providing equal access to our services .
If you need accommodation, please call (360) 902-3900 or TTY (360) 664-0116 .
DR-500-024 (R/10/15)WA
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