AOC-495.12 Rev. 7-15 Page 1 of 2 Doc. Code: ACI COM M O NW E A LT H O F K E lex et justitia Case No. _____________________ Court ________________________ County _______________________ Division ______________________ PLAINTIFF NT U C KY CO Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 189A.340; 189A.420 COMMONWEALTH OF KENTUCKY VS. U RT OF JUS TI APPLICATION TO COURT UPON CONVICTION FOR AUTHORIZATION TO APPLY FOR AN IGNITION INTERLOCK LICENSE AND DEVICE _______________________________________________ Address: _______________________________________ _______________________________________ C E DEFENDANT Comes the above-named Defendant, and requests authorization to apply to the Transportation Cabinet for the issuance of an ignition interlock license and permission to operate a motor vehicle/motorcycle equipped with a functioning ignition interlock device (IID): 1. My privilege to operate a motor vehicle in the Commonwealth of Kentucky is subject to revocation upon conviction forafirstoffensewithaggravatingcircumstancesORsecond or subsequent offense in KRS 189A.010 (a),(b),(e) or (f) OR operating a motor vehicle on a revoked or suspended license pursuant to KRS 189A.090. I have enrolled and am actively participating in or have completed alcohol and substance abuse treatment. I am requesting authorization to apply to the Transportation Cabinet for the issuance of an ignition interlock license. I understand that I must meet the Cabinet's eligibility requirements in order to receive an ignition interlock license. I understand that until the ignition interlock license is authorized by the Transportation Cabinet and issued by the circuit court clerk, I will not be permitted to operate any motor vehicle or motorcycle. I am requesting permission to install IID(s) on the following vehicle/motorcycle(s): (List the make, model, year, and VIN number if known) ______________________________________________________________________________________________ _______________________________________________________________________________________________ I understand that, unless I am indigent, I will be responsible for the reasonable cost for leasing, buying, installing, servicing, and monitoring the IID device and that I must comply with all regulations of the Transportation Cabinet regarding the license and device. I understand that if I receive an ignition interlock license, I will only be permitted to operate a motor vehicle or motorcycle equipped with a functioning IID. q (check if applicable) 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 ofmyjob.Myemployerhasbeennotifiedoftheprohibition. 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 2. 3. 4. 5. 6. 7. 8. Date:__________________________, 2_____ Date:__________________________, 2_____ __________________________________________ Defendant's Attorney (if any) Distribution: White - Court File Yellow - Defendant Pink - County Attorney American LegalNet, Inc. www.FormsWorkFlow.com AOC-495.12 Rev. 7-15 Page 2 of 2 Doc. Code: ACI 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. A requirement of his/her employment, is the operation of an employer-provided motor vehicle or motorcycle. We are aware of the employee's license suspension or revocation of the ability to operate a motor vehicle due to a chargeorconvictionfordrivingundertheinfluence. We are aware of the employee's request to the court that he/she be allowed to install an IID on a vehicle(s) 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. We understand that even if a work exception is granted by the Court, the defendant is restricted from using an employer's nonignition interlock equipped vehicle until the expiration of thirty (30) days from the date of issuance of an ignition interlocklicenseforafirstoffenseortwelve(12)monthsfromthedateofissuanceofanignitioninterlocklicensefor a second or subsequent offense in violation of KRS 189A.010. _____________________________________________ Signature of Employer Title Applicant's Name (6) _____________________________________________ _____________________________________________ Company Name State of: ___________________________ County of: __________________________ Subscribed and sworn to before me this ______ day of _________________________, 2________. My commission expires: __________________________ ______________________________________ Notary Public INSTRUCTIONS TO DEFENDANT: If the Court authorizes you to apply for an ignition interlock license, you must complete the Transportation Cabinet's application form and submit it to the Transportation Cabinet. There is a nonrefundable fee for the application. The Cabinet may refuse approval of an ignition interlock license should your driving history reveal a current withdrawal, denial, suspension, cancellation, or revocation of driving privilege in any state/licensing jurisdiction. You can request a copy of your driver historyfromtheDOTpriortosubmittingyourapplicationandnonrefundablefeetofindoutifyouhaveapending restrictionof your driving privilege. If the Cabinet indicates you are eligible for a license, you must then choose an approved IID provider and have a functioning IIDinstalledonthevehicle(s)and/ormotorcycle(s)youdesignated.AcertificateofinstallationofanIIDmustbe provided to the Transportation Cabinet prior to the issuance of an ignition interlock license. If you are indigent,youmaycompleteAOC-49