Dps Surcharge Indigent Form – Fill Out and Use This PDF

Print Full Name: _______________________________________________

DL/ID/DPS Assigned Number: ____________________________________

Date of Birth (MM/DD/YYYY): ____________________________________

All questions must be answered in full to be reviewed and considered for acceptance into the program.

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The following information will be used to determine your eligibility. NOTE: You will be required to send supporting documentation with this application. If your application is incomplete, it will be returned to you with a request for the additional information required.

Your Household:

I live alone and support myself.

I have dependents and support others.

Please list their name(s) and relationship to you. You are required to provide proof of dependents.

I am a dependent and am supported by someone else. ________

Please list their name(s) and relationship to you. You are required to list their income under “Other Household Income.”

I reside in housing, either partially or completely funded by government, or private assistance.

I am incarcerated

Please list TDCJ or County Jail Inmate Number

Employment & Income Information:

(Provide gross income, before taxes, and unemployment benefits, if applicable)

I am am not employed or self employed

If unemployed, when did you file for unemployment? _____________________

Please explain reason, if you did not file for unemployment: _______________

*Include all of your income received within the past 12 months from all employment, business, or income from rent payments, Social Security, Veteran benefits, interest, dividends, retirement, annuity payments, or any other sources. Income from others household members will be included under “Other Household Income’. (If you entered zero income above, you are required to provide supporting documentation regarding your living status.)

For Office Use Only:

*Other Household Income: This includes all other household income not included previously.

Cash Assets:

I have the following accounts (please list balances):

Checking: $_____ Savings: $_____ Money Market: $_____Pre-Paid/Debit: $_____

Supporting Documentation:

You will be required to submit supporting documentation to verify your eligibility for the Indigency/Incentive Programs. Check those you are submitting with your application.

Do not send original documents. They will not be returned.

A copy of SSI benefits statement.

A copy of the most recent Medicaid benefits statement.

A copy of your two (2) most recent and complete bank statements.

(General overview statements will not be accepted.)

Your most recent 1040 and related 1099.

(Please note that additional evidence of income may be requested to determine most current income status)

Evidence of dependents, if not listed on the previous documents.

A copy of your two (2) most recent pay statements.

A copy of the two (2) most recent pay statements from Other Household income listed above.

A copy of your Unemployment approval or denial letter.

A copy of your Veteran Benefits statement.

Evidence of housing assistance which may include a Government Housing contract.

Other applicable documentation.

NOTICE: Additional documentation may be requested. You will be notified in writing of the specific documentation required. Requested documentation must be received within 30 days of the date on the initial notice, to be considered as part of this application. If you are unable to respond within 30 days, you will be required to fill out and submit a new application with new supporting documentation.

ENTER ADDITIONAL INFORMATION IN THIS SPACE

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Signature of Applicant

Date

INC-A (V3.0 03/16)

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Mail the completed form to:

INDIGENCY/INCENTIVE APPLICATION PROCESSING

PO BOX 16733 – AUSTIN, TX 78761-6733

TOLL FREE (800) 688-6882

Mon – Thur 8AM– 9PM, Fri 8AM – 6PM

Saturday 8AM – 12PM

Page 2 of 2

Indigency/Incentive Programs

These programs provide drivers the ability to comply with surcharges owed under the Driver Responsibility Program and maintain driving privileges. Under the Indigency Program, the surcharges are waived. However, under the Incentive Program, the surcharges are not waived but are reduced. The objective is to ensure drivers can become licensed, obtain financial liability insurance, and continue to keep our roads safe. Any surcharge assessed on or after September 1, 2003 are eligible for the Indigency/Incentive Programs.

The Indigency Program applies to individuals who are living at or below 125% of the federal poverty level, defined annually by the United States Department of Health and Human Services. For approved applicants, surcharges will be waived with accounts totaling a zero balance.

The Incentive Program applies to individuals who are living above 125% but are below 300% federal poverty level, defined annually by the United States Department of Health and Human Services. For approved applicants, the surcharge fees will be reduced by 50% of the total amount assessed (service fees apply).

Once approved for a reduction under the Incentive program, the individual must pay the the reduced balance in full within six (6) months. All surcharge suspensions will be lifted during this period. If the individual does not pay the balance in full by the due date, their driving privileges will be suspended until the reduced balance is paid in full.

These programs will not remove other suspensions on the driving record. To check the status of your driving record, please visit www.texas.gov/driver, then select Driver License and Reinstatement Status.

To Apply – Complete the application in black or blue ink only. The application must be completed in full prior to submission. Use notes section on page 2 for additional information.

You may also apply online at www.txsurchargeonline.com.

PLEASE NOTE: Until your application review is

completed, you must continue to remit the minimum monthly payment by the due date to avoid suspension of your driving privileges.

Supporting Documents - Applicants must include supporting documentation based on answers provided on the application. If submitting an online application, you may upload all documents, including your application. All documents must be complete and accurate. Your application and any supporting documents you provide may be forwarded to the Texas Department of Public Safety for additional review. If your application is found to be fraudulent, it can result in criminal penalties.

Approved - A written notice will be sent to the applicant and will provide the due date and the reduced balance owed.

Denied - A written notice will be sent to the applicant with the reason for the denial.

Status - If you applied online, you can check the status of your application online. Online notices will be available 10 -14 business days after your completed application is submitted. If you applied by mail, written notices take up to 60 days after your completed application is submitted.

Payment-The reduced payment must be received by the due date or driving privileges will be suspended. Available payment methods include: ACE Cash Express, MoneyGram, Western Union, Check, Money Order, or Credit or Debit Card. You can also contact us directly at 1-800-688-6882 or visit www.txsurchargeonline.com.

New Surcharges- If additional surcharges are assessed within 90 calendar days of reduction approval, those surcharges will be automatically reduced and a letter sent with the new balance due. The original due date remains the same. If new surcharges are assessed 91 days or more after the reduction approval, a new application will be required.

All notices will be sent to the address associated with the surcharge account(s).