Free Application for Order to Install Ignition Interlock Device (IID) - Kentucky

AOC-495.4 Rev. 4-01 Page 1 of 2

Doc. Code: AO
01/9/2007 11:41 am

Case No.
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Ver. 1.01

Court APPLICATION FOR ORDER TO INSTALL IGNITION INTERLOCK DEVICE (IID) County Citation #

[ ] Circuit [ ] District

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Commonwealth of Kentucky Court of Justice KRS 189A.340 COMMONWEALTH OF KENTUCKY VS.

___________________ PLAINTIFF

DEFENDANT Name Address

Comes the above-named Defendant, and applies for permission to install IID(s). 1. 2. I was convicted of [ ] DUI, second offense; [ ] DUI, third offense; [ ] DUI, fourth or subsequent offense. Judgment was imposed on ____________________, ________. I am requesting permission to install IID(s) because at final sentencing, in lieu of license plate impoundment: [ ] the court ordered that I be prohibited from operating a motor vehicle or motorcycle without a functioning IID at the conclusion of the license revocation; OR [ ] the court required that I have a functioning IID when operating a motor vehicle or motorcycle at the conclusion of the license revocation; AND I have completed one year of license suspension without any subsequent conviction for a violation of KRS 189A.010 or KRS 189A.090. 3. 4. I am requesting permission to install IID(s) on all motor vehicle(s) and motorcycles(s) I own or lease. I am requesting a WORK EXCEPTION from the IID requirement. I am required to operate an employer-owned [ ] motor vehicle [ ] motorcycle in the course and scope of my employment with (name of employer) __________________________________________________________________________________________. I ask the Court to allow me to operate an employer-provided motor vehicle/motorcycle that is not equipped with IID during regular work hours for the purposes of my job. My employer has been notified of the prohibition. 5. Submitted to the Court with this Application are: (a) Proof of motor vehicle insurance; and (b) If requesting a work exception, my employer has completed the NOTARIZED statement on page 2 of this form. ____________________________________________ Defendant's Signature ____________________________________________ Defendant's Attorney (if any) Pink - County Attorney

Date: _______________________, 2________. To be completed by Judge: [ ] Schedule Hearing [ ] No Hearing Needed Copy Distribution: White - Court File

Yellow - Defendant

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AOC-495.4 Rev. 4-01 Page 2 of 2 Directions to Employer: This statement must be completed and notarized as part of the Applicant's request to install an IID and obtain a work exception.

EMPLOYER'S STATEMENT:
1. 2. 3. 4. 5. ________________________________________________________________ is an employee of this company. Applicant's Name A requirement of his/her employment is operation of an employer-provided motor vehicle or motorcycle. We are aware of the employee's conviction for second or subsequent DUI. We are aware of the employee's request to the Court that he/she be allowed to install an IID on vehicles registered to him/her, either jointly or individually. We are aware of the employee's request for a work exception. If granted by the Court, we understand that the employee will be permitted to operate an employer-provided motor vehicle or motorcycle which is not equipped with an IID for work purposes only and only during work hours. Employee's work schedule is as follows: From: Mon. Tues. Wed. Fri. Sat. Sun. ________ [ ] a.m. [ ] p.m. ________ [ ] a.m. [ ] p.m. ________ [ ] a.m. [ ] p.m. ________ [ ] a.m. [ ] p.m. ________ [ ] a.m. [ ] p.m. ________ [ ] a.m. [ ] p.m. To: ________ [ ] a. m. [ ] p.m. ________ [ ] a. m. [ ] p.m. ________ [ ] a. m. [ ] p.m. ________ [ ] a. m. [ ] p.m. ________ [ ] a. m. [ ] p.m. ________ [ ] a. m. [ ] p.m. ________ [ ] a. m. [ ] p.m.

6.

Thurs. ________ [ ] a.m. [ ] p.m.

_____________________________________________________ Signature of Employer _________________________________________________ Title _______________________________________ Company Name

Subscribed and sworn to before me this ______ day of ________________, 2______. My commission expires: ______________________, 2______. ________________________________________ Notary Public ________________________________________ County

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