New Mexico Taxation & Revenue Department - Motor Vehicle Division
MVD - 10456
REV.
10/15
AFFIDAVIT FOR IGNITION INTERLOCK LICENSE
AFFIDAVIT OF
(Printed Name of Applicant)
STATE OF NEW MEXICO
)
) ss.
COUNTY OF ___________________________ )
I, _____________________________________________, being first duly sworn, state upon oath:
1. I am _______ years of age. My date of birth is ______________________________.
mm/dd/yyyy
2. I have applied for an ignition interlock license.
3. I acknowledge that any vehicle I operate must be equipped with an ignition interlock device.
4. I acknowledge that if I drive a vehicle without an ignition interlock device I am subject to the
provisions for driving with a revoked license. Those sanctions include, but are not limited to:
a. a minimum of seven consecutive days in jail up to 364 days in jail;
b. fine of up to $1,000.00;
c.
immobilization of the motor vehicle;
d. additional license revocation action.
5. I acknowledge that I must maintain the ignition interlock device, including:
a. keeping the maintenance records up-to-date;
b. having the required service and calibration done;
c.
having the log book of the maintenance records in the motor vehicle;
d. having the ignition interlock device and license for a minimum of six (6) consecutive months
with no break in driving status.
6. I acknowledge that I will provide the maintenance records upon request.
___________________________________________
____________________________________________________
________________
Applicant Full Name Printed/Typed
Applicant Signature
Date
State of New Mexico
County of ______________________________
Acknowledgement: On the ___________ day of __________________________ (month) of __________, the above named person,
either personally known to me or identified through satisfactory evidence, appeared to me and indicated that he/she signed the
foregoing document voluntarily for the purposes herein.
_________________________________________________________________
Signature of Notarial Official
My Commission Expires __________________________
Place Notary Seal or Stamp Here
THE FOLLOWING PAGES CONTAIN FREQUENTLY ASKED DWI QUESTIONS