Dl 21Sc Form PDF Details

The DL-21SC form, a crucial document for those navigating the aftermath of certain driving violations, serves multiple key purposes. It acts as a self-certification for individuals mandated to install ignition interlock devices on their vehicles, whether owned or operated by them. Filled out with attention to detail, using either blue or black ink, this form captures essential information, including the driver's identification details and a comprehensive listing of vehicles to which the mandate applies. It demands accuracy in listing the vehicle's plate number, title number, VIN, and year/make, ensuring that the state's Department of Transportation (PennDOT) can accurately assess and enforce compliance. Additionally, it includes a section for the driver to expressly state their ownership or operational permission of the listed vehicles, or, conversely, their lack of any vehicles, which could be crucial for those seeking exemptions based on economic hardship. Vendors, responsible for the installation of the ignition interlock devices, also play a role in the form's process, verifying vehicle information against PennDOT records and certifying the installation. Misstatements on this form carry serious repercussions, classified as misdemeanors that could lead to hefty fines or imprisonment. This document outlines guidelines for its completion and submission, emphasizing the document's role in facilitating legal compliance and ensuring public safety on the roads.

QuestionAnswer
Form NameDl 21Sc Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdl 21s form, dl 21sc, penndot dl21sc form, dl 21 form

Form Preview Example

DL-21SC (4-07)

SELF-CERTIFICATION OF VEHICLE(S) OWNED/OPERATED

PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION

A

DRIVER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

Driver License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address: A P.O. Box number may be used in addition to the actual residence address, but cannot

City

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

be used as the only address.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

VEHICLE INFORMATION (List all vehicles owned or permitted to operate)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plate #

Title #

VIN #

Year/Make

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plate #

Title #

VIN #

Year/Make

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plate #

Title #

VIN #

Year/Make

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Violation occured prior to 10/1/03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

STATEMENT OF OWNERSHIP/NON-OWNERSHIP (Check appropriate box and complete statement)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C I

 

 

 

 

 

 

, hereby state that I own/or have permission to operate the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE PRINT NAME

 

 

 

vehicle(s) listed above.

 

 

 

 

 

 

E I

 

 

 

 

 

 

, hereby state that I do not own any vehicle(s).

 

 

 

 

 

 

 

 

PLEASE PRINT NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H I

 

 

 

 

 

, hereby state that my income meets the guideline

 

 

 

 

 

 

 

 

PLEASE PRINT NAME

 

 

 

established for an economic hardship.

 

 

 

 

 

 

I certify that all information given on this statement is true and correct. I hereby authorize the Department to furnish the Ignition

 

 

 

Interlock Vendor with my vehicle record for the purpose of processing this form.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE IN INK

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

WARNING:

Misstatement of fact is a misdemeanor of the third degree punishable by fine of up to $2,500.00 and/or imprisonment

 

 

 

 

 

 

 

 

up to one year (18 Pa. C.S. Section 4904(b)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

 

STATEMENT OF VENDOR (Complete statement after verifying Section B)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vendor Name

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vendor Address

 

 

City

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I

 

 

 

 

, hereby state that I verified with PennDOT records and installed an ignition interlock

 

 

 

 

 

 

 

 

PRINT NAME

system on the vehicle(s) listed in Section B.

 

 

 

 

 

 

 

I

 

 

 

 

, hereby state that I verified with PennDOT records, and the driver has no vehicles

 

 

 

 

 

 

 

 

PRINT NAME

registered in their name.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I

 

 

 

 

, hereby state that I reviewed the attached financial documentation presented by the

 

 

 

 

 

 

 

 

PRINT NAME

customer and have installed an ignition interlock system on only one vehicle.

 

 

 

 

 

 

 

 

 

I certify that all information given in this statement is true and correct.

 

 

 

 

 

________________________________________

_______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature in Ink

 

 

 

 

 

Date

 

 

 

 

 

 

WARNING: Misstatement of fact is a misdemeanor of the third degree punishable by fine up to $2,500.00 and/or imprisionment up to

 

 

 

 

 

 

 

one year (18 Pa. C.S. Section 4904(b).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEE BACK OF THIS FORM FOR INSTRUCTIONS

TAKE THIS FORM TO:

An ignition interlock vendor who will install an approved ignition interlock device on your vehicle(s). A list of vendors is available at PennDOT's Website at www.dmv.state.pa.us.

Please select Interlock Fact Sheet to obtain this information.

INSTRUCTIONS FOR COMPLETING THIS FORM

This form is to be completed when you are notified that you are eligible for restoration. Your eligibility date can be found on the right corner of the front page of your restoration requirements letter. DO NOT CONTACT A VENDOR TO INSTALL AN IGNITION INTERLOCK DEVICE IF AN ELIGIBILITY DATE IS NOT LISTED. You may contact a Vendor and complete Sections A, B, and C only if an eligibility date is listed. The Vendor completes Section D after the ignition interlock system has been installed.

SECTION A - DEFENDANT INFORMATION

List full name and driver number. You will find your driver number listed in your restoration requirements letter. You can call 1-(717) 412-5300 (for out-of-state calls) or 1-800-932-4600 (for in-state calls) to obtain a Restorations Requirements letter.

SECTION B - VEHICLE INFORMATION

List all vehicles that you own or that you have permission to drive. The title #, tag #, VIN #, and make of vehicle can be found on the registration card. The vendor will verify the information that you supply. You may be required to show current registration and proof of insurance. For additional vehicles, please attach a seperate listing to this form. If the violation occured prior to 10/1/03 you do not have to list vehicle information. Just check the block indicating violation occured prior to 10/1/03.

SECTION C - STATEMENT OF OWNERSHIP/NON-OWNERSHIP

Check the appropriate box indicating owner or non-owner. Complete this section by printing your name, signing your name and dating. Misstatement of fact could result in fines or imprisonment.

If your adjusted gross income is below 200% of the poverty level guidelines, you may be eligible for a hardship exemption. A hardship exemption allows you to install the ignition interlock on only one vehicle. You can obtain detailed information on the financial guidelines for a hardship exemption on PennDOT's website at www.state.pa.us or from an ignition interlock vendor. If you are applying for a hardship exemption, please check the third block and attach a copy of your most recently filed income tax return.

SECTION D - STATEMENT OF VENDOR

Verify the information supplied in Section B. Install the ignition interlock system on the vehicle(s) listed in Section B. Complete Section D by printing your name, signing your name and dating. Forward this form to:

PennDOT

Bureau of Driver Licensing

P.O. Box 68693

Harrisburg, PA 17106-8693

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