DS 699 (REV. /201) WWW REQUEST FOR DRIVER REEXAMINATIONINSTRUCTIONS:1.Complete this form if you wish the Department of Motor Vehicles (DMV) to reevaluate a driver's ability to drive safely.2.Sign this request in the signature block provided. You may request that your name not be revealed to the individual being (FIRST, M.I., LAST)*( )DRIVER CONDITION227 Medical Condition Vision Condition Confused/Disoriented balancing checkbook) DRIVER BEHAVIOR227 Drives in wrong lane Drives on wrong side of the road Makes turns from wrong lane Turns in front of on-coming cars mirrors Slow reactions that may be caused by medications or drugs Drives on sidewalk Makes driving mistakes while talking to passengers You may use the space below to further describe the driver's condition(s) or action(s) which lead you to believe this driver should be reevaluated by DMV. STATE OF CALIFORNIADEPARTMENT OF MOTOR VEHICLES256A Public Service Agency*DS699* American LegalNet, Inc. www.FormsWorkFlow.com Caregiver Vision Specialist Court/Code (Please print)*( )City, State, Zip Code)**X* WWW American LegalNet, Inc. www.FormsWorkFlow.com