Ds 875 Form PDF Details

Are you familiar with the DS 875 form? If not, you should be. This form is used to request a determination of whether an individual is subject to taxation under the Internal Revenue Code (IRC) on wages, compensation, or other income. It's important to understand that this form should only be completed by individuals who are unsure if they are subject to taxation on their wages or other income. Let's take a closer look at the DS 875 form and what it can do for you.

QuestionAnswer
Form NameDs 875 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform ds875, ds875 19a, article road test, ny form road test

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ARTICLE 19-A BIENNIAL BEHIND THE WHEEL ROAD TEST

dmv.ny.gov

INSTRUCTIONS TO CERTIFIED EXAMINER

This test shall not be conducted on the same day as the annual defensive driving performance observation. The test should be taken without

passengers in the vehicle.

If the driver fails the test, he/she is disqualified from driving under Article 19-A. The driver may make a request to the carrier for a reexamination.

DRIVER INFORMATION

Driver’s Last Name

 

First

 

 

M.I.

 

 

 

 

 

 

 

Date of Birth (Month/Day/Year)

Driver License ID Number

State Licensed

License Class

Endorsements

Restrictions

Expiration Date

 

 

 

 

 

 

 

Driver’s Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

CARRIER INFORMATION

Carrier/DBA Name

Legal Name (if different)

Federal ID Number

19-A Business ID Number

 

 

 

VEHICLE INFORMATION

Type of Vehicle

Adult Seating Capacity

GVWR

Vehicle Plate Number

State

 

 

 

 

 

1.

PRE-TRIP TEST

Point Value

 

EN-ROUTE (Continued)

Point Value

 

A. Failed to check wheels, tires

5

 

 

J. Failed to use proper speed - impedes traffic

5

 

B. Failed to check validation of required vehicle stickers

5

 

 

K. Failed to use proper steering control

5

 

C. Failed to check lights

5

 

 

L. Failed to use proper braking

5

 

D. Failed to check windshield, wipers, horn, and steering

5

 

 

M.Failed to use proper acceleration

5

 

E. Failed to check emergency equipment:

 

 

 

N. Failed to use proper speed for conditions

DQ

 

fire extinguisher,and emergency reflectors

5

 

 

O.Failed to anticipate and/or identify hazards

5

 

 

 

 

 

 

F. Failed to check seats and restraints when equipped.

5

 

 

 

 

 

 

 

P. Failed to yield right-of-way

DQ

 

G.Failed to check passenger entry and emergency exits

5

 

 

 

 

 

 

 

Q.Failed to use proper lane/s

10

 

H. Failed to check all gauges, heater, and defroster

5

 

 

 

 

 

 

 

 

 

R. Failed to properly use transmission

5

 

 

 

 

 

 

I. Failed to check all mirrors and adjust as needed

5

 

 

 

 

 

 

 

S. Failed to observe traffic control devices

DQ

 

J. Failed to perform static brake check

5

 

 

 

 

 

4.

PARKING AND BACKING

 

 

K. Failed to properly use seat belt

5

 

 

 

 

 

A. Failed to leave the vehicle to check rear before

 

 

L. Failed to perform 50 ft. brake test

10

 

 

 

 

 

 

backing (no observer)

10

 

 

 

 

 

2.

DEPARTING

 

 

 

B. Failed to observe (backing)

DQ

 

A. Failed to signal

5

 

 

C. Unable to park

DQ

 

B. Failed to observe

10

 

 

D. Failed to properly position the vehicle

5

 

C. Failed to use caution

10

 

 

E. Stopped too far away from, or hit, curb

5

3.

EN-ROUTE

 

 

 

F. Excessive maneuvers in parking

5

 

A. Failed to properly signal

5

 

5.

SIMULATED PROCEDURES FOR RECEIVING/

 

 

 

 

 

 

DISCHARGING PASSENGERS

 

 

B. Failed to observe

10

 

 

 

 

C. Failed to demonstrate proper judgment approaching/at

 

 

 

A. Failed to use caution at approaching/departing,

 

 

intersection; speed, turning, stopping, observing, etc.

10

 

 

receiving/discharging points

DQ

 

 

 

 

 

 

 

 

D. Failed to make proper lane changes; signals ______,

 

 

 

B. Failed to properly activate warning lights/devices

 

 

observes _______, procedure _______

5

 

 

(whereapplicable)

DQ

 

 

 

 

 

 

 

 

E. Failed to regularly check mirrors while driving

5

 

 

C. Lacked knowledge of proper crossing procedures

 

 

 

 

 

 

as required by NYS Education Department

 

 

F. Failed to stop properly at RR crossing

DQ

 

 

 

G.Failed to use proper clutch/engine control

5

 

 

(whereapplicable)

DQ

 

 

 

 

 

 

 

 

 

 

D. Failed to observe pedestrians/passengers or other

 

 

H. Failed to use proper judgment in traffic

10

 

 

 

 

I. Failed to demonstrate proper following distance

DQ

 

hazards at receiving and discharge points

DQ

 

 

 

 

 

 

 

RESULTS

oQUALIFIED oDISQUALIFIED

if disqualified, check all that apply:

 

 

o40 or more points circled

oOne or more disqualification (DQ) item(s) circled

oAny two, or more, 10 point items circled

EXAMINER’S CERTIFICATION (Examinerusepage2foranycomments)

Certified Examiner’s Name

Driver License ID Number

Certificate Number

Certification Class

Endorsements

Restrictions

Expiration Date

CERTIFICATION:I certify that I currently hold a valid examiner certification as required in accordance with Article 19-A of the New York State Vehicle and Traffic Law, that I hold the appropriate class driver license with the proper endorsements, that I have tested the above driver in compliance with Section 6.11 and/or Section 6.15 of Part6oftheCommissioner’sRegulationsandreportedtheresultstotheemployer.Iacknowledgeandunderstandthatknowingly makingafalsestatementinconnection with this report or in any proofs or reports in connection with it for the purpose of deceiving or substituting, or causing another person to deceive or substituting, in connectionwiththisexaminationorreportmaysubjectmetocriminalprosecutionforamisdemeanororfelonyundertheVehicle andTrafficLawand/orPenalLaw.

Certified Examiner’s Signature

X

Date of Test

DS-875 (9/16)

Page 1 of 2

CERTIFIED EXAMINER’S COMMENTS:

DS-875 (9/16)

dmv.ny.gov

Page 2 of 2

 

RESET/CLEAR

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Part # 1 in filling out 19a biennial

2. The subsequent stage would be to submit all of the following blanks: A Failed to signal B Failed to, ENROUTE, A Failed to properly signal B, D Failed to make proper lane, observes procedure, E Failed to regularly check, F Failed to stop properly at RR, B Failed to observe backing C, SIMULATED PROCEDURES FOR RECEIVING, DISCHARGING PASSENGERS A Failed to, receivingdischarging points, B Failed to properly activate, where applicable, C Lacked knowledge of proper, and as required by NYS Education.

F Failed to stop properly at RR, E Failed to regularly check, and ENROUTE of 19a biennial

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Writing section 3 in 19a biennial

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Learn how to fill out 19a biennial step 4

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