Nm Indigent Fund Form – Fill Out and Use This PDF

The NM Indigent Fund Form is a document that can be downloaded from the New Mexico Courts website.

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Nm Indigent Fund Form PDF Details

In today's blog post we will be discussing the NM Indigent Fund Form. This form is used to document an individual's eligibility for benefits through the state of New Mexico's indigent fund. The fund provides financial assistance to eligible individuals who are unable to pay for necessary medical care or meet other basic needs. Today we will go over the basics of the form, including what information is required and how to submit it. Stay tuned for our next post, where we will provide more in-depth information about the fund and its benefits.

We have gathered some basic facts about the nm indigent fund form. You might like to study it just before writing the gaps.

Question	Answer
Form Name	Nm Indigent Fund Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	48
Avg. time to fill out	10 min 6 sec
Other names	new mexico application interlock, mvd application for subsidy ignition lock, indigent fund, new mexico interlock indigent

12

Form Preview Example

State of New Mexico - Department of Transportation	IIDF.Rev 11.07.14 1
Traffic Safety Division (TSD)
INSTRUCTIONS FOR APPLICATION
IGNITION INTERLOCK INDIGENT DEVICE FUND
Under Sec. 66-8-102.3 & 66-2-7.1 NMSA 1978
(Effective July 1, 2010)

1 - IGNITION INTERLOCK FUND BENEFITS

If indigency is granted and provided that money is available in the Interlock device fund, the NMDOT Traffic Safety Bureau shall pay for one vehicle per offender, up to: $50.00 for the cost of installation; $30.00 monthly for verified active usage of the interlock device, and up to $50.00 for the cost of removal. The offender is responsible for all other charges associated with the installation, servicing and removal of the ignition interlock device. The interlock device fund fee collected by MVD shall not be imposed on an indigent person.

2 - WHO QUALIFIES FOR BENEFITS FROM THE INTERLOCK DEVICE FUND ?

Individuals who are required, pursuant to convictions under Section 66-8-102 NMSA 1978 or adjudications on the basis of 32A-2-3 NMSA 1978 or NM driver's license revocations pursuant to the Provisions of the Implied Consent Act or as a Condition of Parole, to drive interlocked.

1)If you have been convicted in New Mexico for Driving Under the Influence of Intoxicating Liquor or Drugs (DUI) and have been court ordered to a period of interlock.

2)If your driver's license has been revoked by the Motor Vehicle Division because of a DUI arrest and you can not drive legally without an Ignition Interlock.

3)If you have been ordered to drive interlocked as a condition of parole.

3 - HOW DO I QUALIFY FOR AN INDIGENCY DETERMINATION ? (APPLICATION PARTS C AND D)

INDIGENCY DETERMINATION BY TRAFFIC SAFETY DIVISION BEGINNING JULY 1, 2010:

Indigency shall be determined by the Traffic Safety Division based on applicant's proof of enrollment in one or more of the following types of public assistance:

	PUBLIC ASSISTANCE PROGRAMS:

TANF -	Temporary Assistance for Needy Families 
GA -	General Assistance 
SNAP -	Supplemental Nutritional Assistance Program (Food Stamps) 
SSI -	Supplemental Security Income 
	Note: SSI is not Social Security Disability

FDPIR - Food Distribution Program on Indian Reservations 

PROOF OF ENROLLMENT DOCUMENT:

Notice of Approval or Form # ISDB003 from Income Support Division Notice of Approval or Form # ISDB003 from Income Support Division Notice of Approval or Form # ISDB003 from Income Support Division Benefit Verification Letter from the Social Security Office

TSD (FDPIR) Verification Form from FDPIR office

Applicants must provide the required PROOF OF ENROLLMENT DOCUMENT listed above with application - a print out of Benefit History will not be accepted.

INDIGENCY DETERMINATION BY COURT, PROBATION & PAROLE PRIOR TO JULY 1, 2010:

You may still qualify for benefits if you were previously declared indigent by Court, Probation and Parole prior to 7/1/10 and if it relates to your license revocation. You must provide a copy of the valid indigency order and complete an application.

A valid indigency order must have client's name, be signed and dated by Judge, Probation or Parole and indicate indigency is for Ignition Interlock.

4 - HOW TO APPLY ?

1)Complete application Parts A, B, C or D (whichever applies), & E, and have signature notarized. Also attach relevant documents

2)Submit application to TSD

5 - HOW TO RECERTIFY (SECOND OR SUBSEQUENT APPLICANTS) ?

If you were previously declared indigent by the Traffic Safety Division you may recertify to extend your benefits from the indigent fund.

1)Complete application Parts A, C or D (whichever applies), & E, have signature notarized and attach relevant documents

2)Submit application to TSD

Applicants must provide current proof of enrollment from Public Assistance Program if declared indigent by TSD after 7/1/10.

6 - WHERE DO I SEND MY COMPLETED APPLICATION ?

(Incomplete applications will be returned to applicant. Also, TSD will not accept faxed or emailed applications)

IF MAILING APPLICATION, MAIL TO ▼

Traffic Safety Division Ignition Interlock Fund

P.O. Box 1149

Santa Fe, NM 87504

Questions should be directed to:

Traffic Safety Division

(505) 827-0427 or 1-800-541-7952

IF DROPPING OFF APPLICATION:

The office that serves all areas is located at:

1122 Cerrillos Road (SB1-N)

Santa Fe, NM 87505

7 - HOW WILL I KNOW IF I WAS APPROVED FOR BENEFITS ?

1)TSD will send letter informing applicant of the indigency status.

-If approved, the letter will indicate benefit effective dates. You will be eligible for subsidy benefits during these effective dates.

-If denied, the letter will list the reason(s) for denial. You may reapply if you later meet the statutory requirements.

-If incomplete, the notice will list the reason(s) application is incomplete. If information is obtained resubmit application for reconsideration.

2)If approved, provide a copy of your approval letter to the Ignition Interlock Provider so you can receive eligible benefits.

3)If approved, TSD will notify MVD of your indigency status. As long as you obtain your initial ignition interlock license between the effective dates, MVD will not charge the interlock device fund fee.

Web link to information and applications: http://dot.state.nm.us/ (Then select Traffic Safety under News & Information)

State of New Mexico - Department of Transportation

TSD USE ONLY

- IIDF.Rev 11.07.14

Traffic Safety Division (TSD)

Refund: 

A D I

APPLICATION FOR SUBSIDY

Apvd By:

2SEQ#:

IGNITION INTERLOCK INDIGENT DEVICE FUND

From:

Under Sec. 66-8-102.3 & 66-2-7.1 NMSA 1978

To:

All information provided is protected under Motor Vehicle Code Confidentiality

A D I

Applicant signature must be notarized

1SEQ#:

NMDOT LOGO

Please print clearly or type / all items must be completed

PART A:

APPLICANT INFORMATION

Applicant Name

Date of Birth

Social Security Number

/

/

-

-

Applicant Address

Driver License Number or NM State Identification Number

Mailing Address (if different)

Telephone Number

(

)

-

City

State

Zip Code

PART B:

IF YOU ARE A FIRST TIME APPLICANT, COMPLETE PARTS B, C or D (whichever applies), & E

Has your license been revoked by MVD?  Yes  No

Date of Revocation:

/

/

If you have been convicted of DUI in NM Court enter current conviction information

Date of Conviction:

/

/

Court / City

Court Case Number

/

If you were convicted by a NM Court, attach a copy of your Judgement & Sentence from court.

Have you been ordered as a condition of parole to drive with an interlock?  Yes  No

Name of Supervising Officer:

If you are required to be interlocked as a condition of parole, attach a copy of your Certificate of Parole.

PART C:

PUBLIC ASSISTANCE PROGRAM INFORMATION (TANF, GA, SNAP, SSI OR FDPIR)

Name of State or Federal Public Assistance Program applicant is currently enrolled in:

Effective Dates of Eligibility

TANF GA

SNAP

SSI (Supplemental Security Income)  FDPIR

From:

/

/

To:

/

/

Please attach proof of enrollment in one of the qualifying Public Assistance Programs (TANF, GA, SNAP, SSI OR FDPIR).

PART D:

IF YOU WERE PREVIOUSLY DETERMINED TO BE INDIGENT BY A NM COURT, PROBATION

& PAROLE OR TSD FOR PURPOSES OF INTERLOCK, COMPLETE PARTS C or D, & E

Was I determined to be indigent by TSD after 7/1/10?

 Yes  No

From Date:

/

/ To Date:

/

/

Was I determined to be indigent by Court, Probation & Parole prior to 7/1/10?

 Yes  No

Date on Order:

/

/

Date Interlock Installed:

/

/

Ignition Interlock Provider / City:

/

Please attach a copy of your Judgement & Sentence if new DUI case.

If determined to be indigent for ignition interlock benefits prior to 7/1/10, attach a copy of your Order Determining Indigency.

PART E:

AGREEMENT, SIGNATURE AND NOTARIZATION

I understand that false and misleading information in this application can be the basis for denial of this Application.

If this Application is approved, I understand that I must install and maintain the ignition interlock device according to Sec. 66-5-503 NMSA 2003 ignition interlock license requirements and Sec. 66-8-102.3 NMSA 2010 Interlock Device Fund. The Division may consider any deviation to be a breach of the agreement which could result in revocation of assistance from the Interlock Device Fund.

I agree to notify the Division within ten (10) business days of any change to any information in this application.
By signing this form, I hereby acknowledge acceptance and understanding of the above statements. Additionally, I certify					NOTARIAL
under penalties of perjury that all information in this Application is true, correct and complete to the best of my knowledge
and belief.					SEAL

	Applicant Signature (Applicant signature must be notarized)		Date:
The foregoing instrument was acknowledged before me this _______ day of ___________ 20______ by _____________________.
			Notary (Please print name)
			My Commission Expires: __________________
	Notary Public Signature		My Commission Expires: __________________

Instructions for completing this application and indigent benefits are on the back of this document or on a separate page depending on printing options

Mail application to: Traffic Safety Division Ignition Interlock Fund; PO Box 1149; Santa Fe, NM 87504

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