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DEPARTMENT OF MOTOR VEHICLES ORDERED

INTERLOCK DEVICE INSTALLATION CONFIRMATION

dmv.ny.gov

INSTALLER:

After installation of device, please fax a copy of the completed form to (518) 473-8229 or

return the original to the motorist.

email to dmv.sm.interlock@dmv.ny.gov and

MOTORIST:

Bring this completed form, along with all other required paperwork, to a Motor Vehicles

office to obtain a New York State license with a Problem Driver Interlock Restriction.

TO BE COMPLETED BY MOTORIST:

NOTE:

You must present a NYS Non-driver ID Card or other photo ID to the installer at the time of installation.

Motorist’s Name: __________________________________________________________________________

Address: __________________________________________________________________________

Date of Birth: __________________________________ NYS Client ID:___________________________

List all vehicles you personally own or operate (do not include vehicles driven for employment):

YEAR

MAKE

VEHICLE IDENTIFICATION NUMBER

CERTIFICATION:

I understand that I am required to have an interlock device installed on any vehicles I own or

operate, including any subsequent vehicles I may obtain. I certify that the information I have given on this form

is true. I understand that the NYS DMV may contact the installer indicated to validate the information provided.

IMPORTANT:

Making a false statement on this disclosure, or in any proof or statement in connection with it, or de-

ceiving or substituting, or causing another person to deceive or substitute in connection with this disclosure, may

subject you to criminal prosecution for a misdemeanor or felony under the Vehicle & Traffic Law and/or Penal

Law.

Motorist Signature:

Date:

TO BE COMPLETED BY INSTALLER:

On ____________________, I installed an Ignition Interlock Device Model ___________________________,

certified by the NYS Department of Health and approved by NYS Division of Criminal Justice Services (DCJS),

in the above named motor vehicle(s). All vehicle operators have been trained in the proper use of the device and

of all maintenance requirements..

IMPORTANT:

Making a false statement on this disclosure, or in any proof or statement in connection with it, or de-

ceiving or substituting, or causing another person to deceive or substitute in connection with this disclosure, may

subject you to criminal prosecution for a misdemeanor or felony under the Vehicle & Traffic Law and/or Penal Law.

Installer Name: __________________________________________________________________________

Installer Address: __________________________________________________________________________

Phone Number: ___________________________________

Installer Signature:

Date:

DS-21 (3/15)

Form Ds-21 - Department Of Motor Vehicles Ordered Interlock Device Installation Confirmation

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