Form Restricted PDF Details

In the heart of Des Moines, Iowa, individuals seeking to navigate the complexities of regaining driving privileges after a suspension or revocation will find a pivotal ally in Form 430100, the Temporary Restricted License Application. Directed to the Iowa Department of Transportation, Office of Driver Services, this form embodies a beacon of hope for those wishing to resume essential daily activities, particularly related to employment. Comprehensive in its nature, the form requires detailed information from applicants, emphasizes the necessity of reviewing Iowa Code Chapter 321J, Section 321.208 for eligibility, and outlines a process that includes examination, a reinstatement fee, and verification steps. Particularly noteworthy is the division of the application into sections catered to specific needs, including employment and self-employment considerations. Moreover, it connects applicants with further obligations such as the installment of an Ignition Interlock Device for OWI revocations and the adherence to financial responsibilities. With additional stipulations for Iowa residents versus non-residents and a stern reminder about the susceptibility of the temporary license to cancellation upon infraction, Form 430100 serves as a comprehensive guide for those on the path to reinstating driving privileges within specific, regulated bounds.

QuestionAnswer
Form NameForm Restricted
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesia temporary restricted license application, iowa form temporary, iowa form application, iowa temporary

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Form 430100 (07-11)

TEMPORARY RESTRICTED LICENSE APPLICATION

All information must be sent to: Iowa Department of Transportation

 

Office of Driver Services

 

P.O. Box 9204

 

Des Moines, Iowa 50306-9204

For additional information call:

1-800-532-1121 or 515-244-8725

Please review "Operation of Iowa Code Chapter 321J, Section 321.208 And Your Rights" (Form 432019) to see if eligible for Temporary Restricted License.

THE ENCLOSED APPLICATION MUST BE COMPLETED IN DETAIL. ALL APPLICANTS MUST FILL OUT SECTION A. IF APPLICATION IS FOR PURPOSES OTHER THAN EMPLOYMENT FILL OUT ONLY SECTION A. ALL APPLICANTS SHOULD REVIEW AND FOLLOW THE INSTRUCTIONS ON THE REVERSE SIDE OF THIS DOCUMENT.

PLEASE NOTE: This is an application only. If you meet all requirements for a temporary restricted license, the Department will send you notice that your application has been approved. You will then be directed to a driver license station where you must pass the required examinations (vision screen, knowledge exam, and drive test), and pay a $20.00 reinstatement fee and the fee for a temporary restricted license. You are not authorized to drive until all of this has been completed and a temporary restricted license has been issued to you. The Department and law enforcement may verify the information provided on this application.

SECTION A

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

Date of Birth:

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

Driver License No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

State:

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OWI SANCTIONS ONLY: Were you involved in an accident when the OWI occurred?

YES

NO

SECTION B - For employment purposes only, complete the following:

Name of Employer:

City:

Work Hours:

Describe on the job driving:

State: Zip:

AM PM to

Work Address:

AM

PM Days of the Week:

I CERTIFY UNDER PENALTY OF PERJURY AND PURSUANT TO THE LAWS OF THE STATE OF IOWA THAT THE PRECEDING STATEMENTS ARE TRUE AND CORRECT.

Applicant's Signature

EMPLOYER'S STATEMENT

I understand this is an application for a Temporary Restricted License for work purposes. I hereby verify that the above statements are true and correct. By signing, I certify I am the employer for the above named applicant and/or I have the authority to sign on behalf of the employer.

Business Name:

Employer's Signature:

 

Title:

 

 

 

 

 

 

 

 

Phone:

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION C - For self-employed purposes only, complete the following:

I understand this is an application for a Temporary Restricted License for work purposes. I hereby verify that the above statements are true and correct. By signing, I certify I am Self-Employed and do not have an employer from whom any compensation is received. I agree to notify the Department of any self-employment changes.

Job Description:

Work Address:

Work Hours:

Business Name:

AM

PM to

AM

PM Days of the Week:

Phone:

I CERTIFY UNDER PENALTY OF PERJURY AND PURSUANT TO THE LAWS OF THE STATE OF IOWA THAT THE PRECEDING STATEMENTS ARE TRUE AND CORRECT.

Applicant's Signature

(Page 1 of 2)

TEMPORARY RESTRICTED LICENSE INSTRUCTIONS: (Please read instructions carefully.)

Iowa law provides that the Department may, upon application and approval, issue a Temporary Restricted License (Work Permit) to a person whose license is suspended or revoked to allow the person to drive at specified times and for specified purposes which can be verified by the Department.

STATEMENTS FOR ITEMS 1 THROUGH 7 MUST BE ON BUSINESS LETTERHEAD AND SIGNED BY THE APPROPRIATE PERSON(S):

1.If the request is to provide transportation for Continuing Health Care for you or a dependent, send a statement from the health care provider verifying the need and stating the location and dates of the treatment.

2.If the request is to attend Continuing Education, send a statement from the educational institution verifying enrollment, stating the course of study, the location, the time of attendance, and signature from the School Administrator or the School Registrar.

3.If the request is to attend Substance Abuse Treatment, send a statement from the treatment provider or Probation Officer, verifying participation in the program, stating the location and the time of attendance.

4.If the request is to perform Court Ordered Community Service, send a copy of the Court Order and an administrator's statement describing the Community Service and stating the location, dates and hours of service.

5.If request is to transport dependent children to and from child care when necessary to continue employment, you must send a statement from the child care provider stating the child care address, phone number and dates and times of service.

6.If the conditions of your employment change, you must send a new employer's statement or you may request a new application and one will be sent to you. You are not authorized to drive until a new restriction supplement has been issued by the department.

7.If the request is to attend Probation or Parole meetings, send a statement from your probation or parole officer verifying participation in the program and stating the location and time of attendance.

8.File proof of Financial Responsibility (SR-22) in accordance with Iowa Code, Chapter 321A, when required and pay civil penalty (see #10).

9.If you had an OWI revocation, you may be required to provide to the Department a Certificate of Installation of an Ignition Interlock Device, of a type approved by the Department of Public Safety, on every vehicle owned and operated by you in accordance with Iowa Code 321J. If this requirement applies to you, the Department may not issue you a temporary restricted license until this has been done. If you are not certain whether you are required to provide a Certificate of Installation of an Ignition Interlock Device, please contact the Department at 800-532-1121. A list of approved installers of ignition interlock devices may be found at: www.iowadot.gov/mvd/ods/interlock.htm

10.Pay any required civil penalties as follows: For an OWI revocation pay a $200 civil penalty. For other offenses, effective July 1, 1997, Iowa law requires a civil penalty when the Department suspends, revokes, or bars a motor vehicle license or nonresident operating privilege for a conviction under Chapter 321 and any suspension, revocation or bar under Chapter 321A. Persons age 20 and older pay a civil penalty of $200. For persons age 19 and under, a civil penalty of $50 is required. The payment must be made by cashier's check, certified check or money order payable to the Treasurer, State of Iowa and mailed or delivered to: Iowa Department of Transportation, Office of Driver Services, P.O. Box 9204, Des Moines, IA 50306-9204. DO NOT SEND CASH.

11.If You Are An Iowa Resident: This is an application only. If you meet all requirements for a temporary restricted license, the Department will send you notice that your application has been approved. You will then be directed to a driver license station where you must pass the required examinations (vision screen, knowledge exam, and drive test), and pay a $20.00 reinstatement fee and the fee for a temporary restricted license. You are not authorized to drive until all of this has been completed and a temporary restricted license has been issued to you. The Department and law enforcement may verify the information provided on this application.

12.If You Are A Non-Resident: You are not eligible for a Temporary Restricted License in Iowa.

13.If your motor vehicle license or non-resident operating privilege has been revoked for any reason under Chapter 321J (whether as a result of a

court order or administrative action), the license or privilege may not be reinstated until you present proof of completion of a course for drinking drivers, and present proof of completion of a substance abuse evaluation and treatment or rehabilitation services.

The Department shall determine the restrictions of your Temporary Restricted License. Your operating privileges will be restricted and your license will remain suspended or revoked except when driving during the times and the reasons specified by the Department. NOTE: One moving violation may result in cancellation of your Temporary Restricted License.

Iowa Code section 321.182 requires you to notify the Iowa Department of Transportation within 30 days of any change in your mailing address. This notification must be made in writing or in person at any driver license station.

(Page 2 of 2)

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