Broome County Ignition Interlock Devise Program Request for IID De-Installation / Restriction Removal

Note: This form is only a REQUEST for removal. It does not grant authorization to remove the IID or the license restriction. Please return this form within two weeks of your eligibility date. Defendants who have not installed an IID will have the interlock restriction on their license for the duration of their Conditional Discharge.

Date of Request

Name of Defendant

Email Address

Phone Number

Mailing Address

City

State

Zip

Date of Birth

Driver's License #

Sentencing Court

Sentencing Judge

Date Defendant Was Convicted

IID Installed on Vehicle?

IID Vendor

Vehicle #1

Owner

Vehicle Make

Model

Year

Color

V.I.N.

Plate Number

If you are requesting an IID be removed from a vehicle, please provide the vehicle identification information below. If you do not have an IID, do not fill this section out.

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Broome County Ignition Interlock Devise Program Request for IID De-Installation / Restriction Removal

NEAL J. HAIGHT ACTING DIRECTOR

NEAL J. HAIGHT
ACTING DIRECTOR