New York State Department of Motor Vehicles REQUEST FOR DRIVER REVIEW www.dmv.ny.gov INSTRUCTIONS: G This form is to be used by concerned citizens to report a driver who appears to be unable to drive safely. (Law enforcement personnel must use form DS-5, “Police Agency Request for Driver Review”; physicians must use form DS-6, “Physician’s Reporting Form”). G The Department will not act on your request unless you complete all four parts below and on Page 2, and provide all required information. Please provide as much factual detail as possible. G Sign the completed form in the presence of a notary public, and mail the original signed and notarized form to: Medical Review Unit New York State Department of Motor Vehicles 6 Empire State Plaza, Room 220 Albany, NY 12228 Forms that are not notarized will not be accepted. Be aware that the review you are requesting may lead to the suspension or revocation of the driver’s license of the person you are reporting. G G PART 1 - Identification of the person whose ability to drive is in question (Please print.) Last Name (Required) First Name (Required) M.I. Date of Birth (if not known, give approximate age) (Required) Street Address (Required) City (Required) State (Required) Make of Vehicle the Person Normally Drives Color of Vehicle Zip Code License Plate Number PART 2 - Your identification (Please print.) A representative of the NYS DMV may contact you concerning your request for driver review. Your Date of Birth (Required) Your Name (Print name in full) - (Required) Client ID No. (9-digit number from your NYS Driver License or Non-Driver ID card) Your Home Address (Include Street & Number) - (Required) City (Required) State (Required) Zip Code (Required) Your Daytime Telephone Number (Area Code) - (Required) Your relationship to the driver you are reporting: Daughter Son Sister Brother Spouse Mother Father Neighbor Other (explain) PART 3 - Your reasons for reporting this driver Explain why you feel the person you identified in Part 1 should have his/her driving abilities reviewed. Be as specific as possible, and include specific incidents, observations, dates, locations, etc. DS-7 (3/11) (Part 3 is continued on Page 2) PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com PART 3 - (Continued from Page 1) If you know other people who agree with your assessment of this driver, who DMV may contact, please identify them below: Name Address Daytime Telephone Number Name Address Daytime Telephone Number Name Address Daytime Telephone Number Name Address Daytime Telephone Number PART 4 - CERTIFICATION: I certify that the information I provided above is true and accurate. I understand that any false statement given by me may be punishable by law. ± (Your Signature - Sign name in full) (Date - Month/Day/Year) A Notary Public must complete the following: State of ______________________________ County of __________________________________ ss: on this _______________________________ day of _____________________________________, 20_______, before me personally appeared ___________________________________________ to me known and known to me to be the same person described in and who executed the forgoing instrument, and s/he duly acknowledged to me that s/he executed the same. _________________________________________ Notary Public, State of ___________________________________________ (Please affix stamp) DS-7 (3/11) PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com