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For Department Use Only
Approved Denied By
Ignition Interlock Device
Financial Assistance Application
Use this form to apply for assistance with the costs of Ignition Interlock Device (IID) installation, removal, and
leasing the IID.
We will notify you in writing if you have been approved or denied. For more information on IID Assistance,
visit dol.wa.gov
. When completed, mail, email, or fax this form and . When completed, mail, email, or fax this form and all required documentsall required documents to: to:
Driver Records
Department of Licensing
PO Box 9030
Olympia, WA 98507
Email: [email protected]
Fax: (360) 570-7824
Applicant
PRINT OR TYPE Name (Last, First, Middle initial) Driver license number State
Date of birth 10-digit phone number Email
Documentation – Applications without required proof will be denied. Attachments will not be returned.
Assistance Eligibility
Check and provide proof for one of the following, if applicable – attached proof must reect current benets
Department of Social and Health Services (DSHS) benets – DSHS benets/award letter
Medicaid/Medicare – Welcome packet or benets/award letter from the state
Court appointed attorney – Award letter from the court or signed letter from attorney on letterhead
Poverty-related veteran’s benets – VA benets/award letter
Refugee resettlement benets – Benets/award letter
Currently involuntarily committed to a public mental health facility – Court order
If none of the above apply, complete the items below – Applications without required proof will be denied.
Income Verication
Answer the following and provide proof
1. Do you have any dependents? If yes, how many? (include yourself) ....................
2. Monthly Income – If you have no income or don’t have proof, attach a signed
written statement explaining this. If you have income, submit proof, such as
most recent 2 month’s pay stubs, copy of most recent federal tax return, or
most recent W-2s.
a. Combined monthly take-home pay.............................................$
b. Contribution from any family member or other person living in the household who is
helping with your basic living costs ............................................$
c. Interest, dividends, or other income ............................................$
d. Pensions, annuities, and /or social security ......................................$
I declare under penalty of perjury under the law of Washington that the foregoing is true and correct. I authorize
the Department of Licensing to verify all information provided.
Date and place (city or county) signed Applicant signature
RCW 10.101.010; 46.20.308
DR-500-024 (R/11/22)VWA
When you have completed this form, print it out and sign here.
