New York State Department of Motor Vehicles APPLICATION FOR TINTED WINDOW EXEMPTION The front windshield and side windows on both sides of any vehicle operating in New York State must allow at least 70% of any light to pass through. The rear window may allow less than 70% of any light to pass through if the vehicle has mirrors on both sides that can be adjusted so the driver has a clear view of the road and traffic conditions behind the vehicle. The rear side windows of any station wagon, sedan, hardtop, coupe, hatchback or convertible must also allow 70% of any light to pass through. The law provides an exemption for any person who, for medical reasons, must be shielded from direct sunlight. The person who requests an exemption may be either the driver or someone who is a regular passenger in the vehicle. NYS Health Department regulations specify that only the following medical conditions can be used to justify an exemption from the limits on light transmittance: l l l porphyria xeroderma pigmentosa severe drug photo-sensitivity INSTRUCTIONS: To request a medical exemption, send the following three items to the address at the bottom of this page: l l l this completed application; and a photocopy of the vehicle registration receipt; and a physician’s statement, on physician’s letterhead (including the New York State Professional License Number), describing the presence of a medical condition which requires that the applicant or someone other than the applicant be shielded from sunlight. If the statement is from an out-of-state physician, the name of the state in which the physician is licensed, and his/her license, certificate or registration number, must be included. *Please Note: Based on the medical information submitted, our reviewer may ask for further medical details, or may request additional information from a pertinent sub-specialist, ex: dermatologist; optometrist. Please provide the following information as it appears on the vehicle registration. Last Name First M.I. Apt. # Address (Number and Street) City State Zip Code If a medical exemption is requested for someone other than the registered owner of the vehicle, please provide the following information about that person. Last Name First M.I. Apt. # Address (Number and Street) City State Zip Code I am requesting a tinted window exemption certificate, as allowed by Section 375 (12-a) (c) of the New York State Vehicle and Traffic Law. Vehicle Registrant’s Signature ç ________________________________________________________ (Sign Name in Full) Return this application to: Department of Motor Vehicles, Driver Improvement Bureau, Medical Review Unit, 6 Empire State Plaza, Room 220B, Albany NY 12228 MV-80W (5/11) www.dmv.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com