Form Dl 925 - Ignition Interlock Device (Iid) Installation And Removal Request

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925
IGNITION INTERLOCK DEVICE (IID)
STATE OF CALIFORNIA
INSTALLATION & REMOVAL REQUEST
®
DEPARTMENT OF MOTOR VEHICLES
A Public Service Agency
CLEARLY PRINT information and fax to DMV at (916) 657-9042
SECTION 1 — DRIVER INFORMATION
DRIVER LICENSE NUMBER
BIRTH DATE (MM/DD/YYYY)
FULL NAME (LAST NAME)
FIRST NAME
MIDDLE NAME
SECTION 2 — INSTALLER INFORMATION
DATE OF REQUEST (MM/DD/YYYY)
REQUEST IS FOR:
Installation
Removal
IID INSTALLER NAME
INSTALLER LICENSE NO.:
STREET ADDRESS
CITY
STATE
ZIP CODE
CONTACT NAME
PHONE NUMBER
FAX NUMBER
(
)
(
)
Ext
FOR DMV USE ONLY — ELIGIBILITY FOR INSTALLATION OR REMOVAL
For IID Installation
For IID Removal
ELIGIBLE ON
NUMBER OF MONTHS IID REQUIRED
ELIGIBLE ON
Submit
DL 920
DL 924
ID-110
No, not eligible
No, not eligible
Court ordered
Unsigned requests are only entitled to the information above.
SECTION 3 — DRIVER AUTHORIZATION
I hereby authorize the Department of Motor Vehicles to provide the information listed below for a full assessment of
the IID eligibility requirements to:
NAME OF IID INSTALLER
DRIVER’S SIGNATURE
DATE
X
FOR DMV USE ONLY — ADDITIONAL REQUIREMENTS
If not eligible for IID installation, driver needs:
If not eligible for IID removal, driver needs:
Suspension/Revocation not completed
Completion of
-month program
Enrollment for
-month program
IID term not completed
Completion of 12 months of 18-month program
Contact county court (see below)
Completion of 12 months of 30-month program
Other:
SR 22 proof of financial responsibility
Fee $
Other outstanding action: customer must contact DMV at (916) 657-6525 for additional information
This request contains insufficient/incorrect information. Please provide items checked above and resubmit.
MAU Technician ID
Date Faxed to Installer
This information is intended only for the use of the IID Installer to which it is addressed and may contain information that is privileged, confidential, and
exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering
the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If
you received this in error, please notify us immediately at (916) 657-8739.
DL 925 (REV. 3/2011) WWW

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