DMV DL 120 Form PDF Details

The DMV DL 120 form, termed the Junior Permit Statement of Facts, serves as a critical application for young individuals seeking driving privileges under specific hardship conditions in the United States. Catering to applicants aged between 14 and 18, the form facilitates a streamlined process for acquiring a noncommercial driver license or identification card when other modes of transportation prove inadequate. Applicants must demonstrate a tangible necessity for driving, such as illness, educational demands, work responsibilities, or the operation of a family enterprise. The form requires detailed information including the applicant's personal details, a comprehensive explanation of the transportation inadequacy, and justification for the hardship claim. Furthermore, it mandates the submission of additional documents, like an Application for a Noncommercial Driver License/Identification Card (DL 44), and outlines the need for completion of approved driver education and training courses upon the issuance of the permit. To substantiate the hardship conditions, certifications from doctors, school principals, or employers may be requested, alongside parent or guardian authorization, highlighting the rigorous and thorough approach adopted to ensure that driving privileges are granted under legitimate circumstances.

QuestionAnswer
Form Name DMV DL 120 Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names how to apply for a junior permit in california, how to get a junior permit in california, how to get a junior permit, junior permit in california

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JUNIOR PERMIT STATEMENT OF FACTS

120

A Public Service Agency

(SECTIONS 12513, 12514 C.V.C.)

 

COMPLETED application must be submitted in person to the local office of the Department of Motor Vehicles. Attach separate sheet if more space is needed. Incomplete information may delay decision. An Application for a Noncommercial Driver License/Identifi- cation Card (DL 44) must be submitted with this form.

Permit can only be approved if certain HARDSHIP conditions are shown to exist. ALL other transportation must be inadequate. Applicant must be at least 14, but under 18 years of age.

STATEMENT OF FACTS BY PARENTS

CHECK ONE OR MORE OF THE FOLLOWING

I.

Illness

II.

School

III.

To and From Work

IV.

Family Enterprise

APPLICANT'S FULL NAME

 

 

DATE OF BIRTH

 

HOME PHONE

 

DAY PHONE (if different)

 

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

CITY

 

 

ZIP CODE

IF PRIOR JUNIOR PERMIT APPLICATION MADE FOR APPLICANT OR OTHER FAMILY MEMBER, GIVE NAME AND YEAR

ESTABLISH THAT TRANSPORTATION IS INADEQUATE

DESCRIBE APPLICANT'S ESSENTIAL DRIVING NEEDS

DISTANCE FROM APPLICANT'S RESIDENCE TO NEAREST PUBLIC TRANSPORTATION

LOCATION BY STREETS OF NEAREST BUS OR TRAIN STOP

 

 

DESCRIBE BEST BUS OR TRAIN ROUTE, GIVE NAME OF SERVICE, TELEPHONE NUMBER, NAME OR NUMBER OF INDIVIDUAL LINE(S), DEPARTURE, TRANSFER AND ARRIVAL TIMES, ETC.

LIST NAMES AND DRIVER LICENSE NUMBERS OF ALL DRIVERS IN THE HOUSEHOLD

EXPLAIN SPECIFICALLY WHY EACH DRIVER IN THE HOUSEHOLD CANNOT DO THE REQUIRED DRIVING. INCLUDE DAILY WORK OR SCHOOL AND TRAVEL SCHEDULE OF EACH DRIVER, NATURE AND LOCATION OF EMPLOYMENT AND DISTANCE FROM HOME AND APPLICANT'S SCHOOL. INCLUDE NUMBER OF EMPLOYEES, IF SELF-EMPLOYED

IF HOUSEHOLD INCLUDES NON-DRIVING ADULT OR MINOR OLDER THAN APPLICANT, GIVE NAME AND RELATIONSHIP TO APPLICANT AND EXPLAIN WHY PERSON CANNOT/DOES NOT DRIVE. (If medical reason, separate Statement of Facts by Physician needed.)

EXPLAIN WHY CARPOOLS, TAXIS, BICYCLES, WALKING, VANPOOLS, ETC. CANNOT BE USED

DRIVER EDUCATION AND TRAINING

HAS APPLICANT COMPLETED APPROVED DRIVER EDUCATION AND TRAINING COURSES? (If no, reason.)

Yes No

IF A JUNIOR PERMIT IS ISSUED, CERTIFICATES OF COMPLETION OF DRIVER EDUCATION AND TRAINING MUST BE ON FILE WITHIN SIX MONTHS OR THE PERMIT MUST BE CANCELLED. DESCRIBE PLAN TO COMPLETE COURSES IF PERMIT IS ISSUED.

I. ADDITIONAL INFORMATION REQUIRED IF REQUEST IS DUE TO FAMILY ILLNESS

ESTABLISH THE RELATIONSHIP BETWEEN THE ILL PERSON AND THE APPLICANT

INDICATE WHETHER OR NOT THE PERSON'S ILLNESS PREVENTS THEM DRIVING AND FOR HOW LONG

 

Yes

No

If yes, how long?

II. ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON NEED FOR TRANSPORTATION TO AND FROM SCHOOL

DESCRIBE TRANSPORTATION ARRANGEMENTS TO DATE

EXPLAIN THE CHANGE IN CIRCUMSTANCES THAT NOW MAKES THE APPLICANT'S OPERATION OF A MOTOR VEHICLE ESSENTIAL

III. ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON NEED FOR TRANSPORTATION TO AND FROM WORK

EXPLAIN CHANGES IN FAMILY CIRCUMSTANCES THAT NOW MAKE APPLICANT'S INCOME ESSENTIAL IN THE SUPPORT OF THE FAMILY

APPLICANT'S NET OR TAKE HOME INCOME

DESCRIBE USE OF APPLICANT'S INCOME

$PER

ALL OTHER SOURCES OF FAMILY'S INCOME

IV. ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON FAMILY ENTERPRISE

NAME AND ADDRESS OF ENTERPRISE

NATURE AND TYPE OF ENTERPRISE

YEARS IN BUSINESS

NO. OF EMPLOYEES (include family members)

 

 

 

EXPLAIN SPECIFICALLY WHY EACH EMPLOYEE CANNOT DO THE REQUESTED DRIVING. INCLUDE DAILY WORK AND TRAVEL SCHEDULE OF EACH EMPLOYEE

DL 120 (REV. 9/91) WWW

Continue on reverse

 

Name ____________________________________ DOB _____________________

SHOW HOW THE FAMILY INCOME DEPENDS ON THE OPERATION OF THE ENTERPRISE

EXPLAIN WHY SOMEONE CANNOT BE HIRED TO DO THE REQUESTED DRIVING

EXPLAIN WHY ENTERPRISE WOULD BE UNABLE TO CONTINUE UNLESS APPLICANT OPERATES A MOTOR VEHICLE

HOURS PER WEEK APPLICANT WOULD WORK

SALARY (If any)

 

 

PARENTS AUTHORIZATION AND CERTIFICATION: (Both parents must sign.)

I/We hereby authorize the Department of Motor Vehicles to ask for and receive any additional information needed to determine eligibility for a Junior Permit from physician, school principal, and/or employer certifying to a Statement of Facts. Medical information is confidential under Section 1808.5 CVC.

I /We hereby certify, under penalty of perjury, that all statements on this application are true. (Perjury is punishable by imprisonment or fine or both.) Both parents must sign unless one has custody and writes: “I have sole custody.”

FATHER'S SIGNATURE

DATE

MOTHER'S SIGNATURE

DATE

X

 

 

X

 

 

ADDRESS

CITY

ZIP

ADDRESS

CITY

ZIP

PARENTS: Have physician(s) complete separate Statement of Facts (I) for each family member whose disability affects driving or transportation needs. If hardship condition is to and from school, have school principal complete Statement of Facts (II). If hardship condition is to and from work, have employer complete Statement of Facts (III).

 

 

 

I. STATEMENT OF FACTS BY PHYSICIAN

 

NAME OF PATIENT

 

 

 

DIAGNOSIS

 

 

 

 

 

 

 

 

PRINCIPAL SIGNS AND SYMPTOMS

 

 

 

 

 

 

 

 

PROGNOSIS (INCLUDE PROBABLE DATE WHEN SUFFICIENT RECOVERY WILL HAVE BEEN MADE TO TERMINATE THE EMERGENCY. IF CONDITION IS CHRONIC, PHYSICIAN MUST STATE THAT FACT.)

 

 

 

 

 

DOES PATIENT'S CONDITION RULE OUT DRIVING?

Yes

No

IF AVAILABLE, DOES PATIENT'S CONDITION RULE OUT USE OF PUBLIC TRANSPORTATION?

 

 

 

 

 

If yes,

Permanently Temporary—how long?

Yes

No

 

 

 

II. STATEMENT OF FACTS BY SCHOOL PRINCIPAL

 

STUDENT'S NAME

 

 

 

LENGTH OF ATTENDANCE

STUDENT'S DAILY SCHOOL HOURS

 

 

 

 

 

 

 

EXPLAIN WHY SCHOOL AND OTHER TRANSPORTATION IS INADEQUATE FOR REGULAR ATTENDANCE AT SCHOOL

NAME AND LOCATION OF SCHOOL

DISTANCE: RESIDENCE TO SCHOOL TO SCHOOL BUS STOP (if any) SCHOOL TO PUBLIC TRANSPORATION APPROXIMATE DATE PERMIT NO LONGER NEEDED LAST DAY OF STUDENT'S SCHOOL YEAR

III. STATEMENT OF FACTS BY EMPLOYER

NAME OF EMPLOYEE

DATE OF EMPLOYMENT

SALARY

$PER

ADDRESS AND CROSS STREETS OF PLACE WHERE APPLICANT REPORTS TO WORK

TYPE OR NATURE OF EMPLOYMENT

WORK HOURS

MONDAY THRU FRIDAY

SATURDAY

SUNDAY

WEEKLY TOTAL

 

(STARTING &

 

 

 

 

 

ENDING TIMES)

 

 

 

 

PERMIT TO EMPLOY MINOR ON FILE? IF YES, GIVE NAME, TITLE AND TELEPHONE NUMBER OF ISSUING PARTY

 

 

EXPIRATION DATE

Yes No

DISTANCE FROM APPLICANT'S RESIDENCE TO PLACE OF EMPLOYMENT

DISTANCE FROM PLACE OF EMPLOYMENT TO PUBLIC TRANSPORTATION

CERTIFICATION TO BE COMPLETED BY:

Physician

School Principal

Employer

I certify, under penalty of perjury, that the above statements are true. (Perjury is punishable by imprisonment or fine or both.)

NAME OF SIGNER (print or type)

TITLE

ADDRESS

CITY

 

ZIP

 

 

 

SIGNATURE

DATE

TELEPHONE NO.

X

 

(

)

For further information, contact: Local DMV Office or Driver Safety Review Unit in Sacramento at (916) 657-6452.

FOR LOCAL DMV USE — I have reviewed the above Statement of Facts and my recommendation and reason(s) are:

Signature of Examiner: X

Office:

Date:

 

 

 

DL 120 (REV. 9/91) WWW

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2. The third stage is usually to complete the following fields: DRIVER EDUCATION AND TRAINING HAS, Yes, IF A JUNIOR PERMIT IS ISSUED, I ADDITIONAL INFORMATION REQUIRED, ESTABLISH THE RELATIONSHIP BETWEEN, INDICATE WHETHER OR NOT THE, II ADDITIONAL INFORMATION REQUIRED, Yes, If yes how long, EXPLAIN THE CHANGE IN, III ADDITIONAL INFORMATION, APPLICANTS NET OR TAKE HOME INCOME, DESCRIBE USE OF APPLICANTS INCOME, PER ALL OTHER SOURCES OF FAMILYS, and IV ADDITIONAL INFORMATION REQUIRED.

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