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 |
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| Form Name | Nm Indigent Fund Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | interlock assistance nm, nm interlock indigent fund, new mexico indigent, interlock fund assistance |
State of New Mexico - Department of Transportation |
IIDF.Rev 11.07.14 1 |
Traffic Safety Division (TSD) |
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INSTRUCTIONS FOR APPLICATION |
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IGNITION INTERLOCK INDIGENT DEVICE FUND |
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Under Sec. |
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(Effective July 1, 2010) |
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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
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2)If your driver's license has been revoked by the Motor Vehicle Division because of a DUI arrest and you can not drive legally without an Ignition Interlock.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:
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PUBLIC ASSISTANCE PROGRAMS: |
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TANF - |
Temporary Assistance for Needy Families |
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General Assistance |
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Supplemental Nutritional Assistance Program (Food Stamps) |
SSI - |
Supplemental Security Income |
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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)
IF DROPPING OFF APPLICATION:
The office that serves all areas is located at:
1122 Cerrillos Road
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)
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State of New Mexico - Department of Transportation |
TSD USE ONLY |
- IIDF.Rev 11.07.14 |
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Traffic Safety Division (TSD) |
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Refund: |
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A D I |
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APPLICATION FOR SUBSIDY |
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IGNITION INTERLOCK INDIGENT DEVICE FUND |
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Under Sec. |
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All information provided is protected under Motor Vehicle Code Confidentiality |
A D I |
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Applicant signature must be notarized |
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1SEQ#: |
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NMDOT LOGO |
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Please print clearly or type / all items must be completed |
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PART A: |
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APPLICANT INFORMATION |
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Applicant Name |
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Date of Birth |
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Social Security Number |
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Applicant Address |
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Driver License Number or NM State Identification Number |
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Mailing Address (if different) |
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IF YOU ARE A FIRST TIME APPLICANT, COMPLETE PARTS B, C or D (whichever applies), & E |
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Has your license been revoked by MVD? Yes No |
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Date of Revocation: |
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If you have been convicted of DUI in NM Court enter current conviction information |
Date of Conviction: |
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If you were convicted by a NM Court, attach a copy of your Judgement & Sentence from court. |
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Have you been ordered as a condition of parole to drive with an interlock? Yes No |
Name of Supervising Officer: |
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If you are required to be interlocked as a condition of parole, attach a copy of your Certificate of Parole. |
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PUBLIC ASSISTANCE PROGRAM INFORMATION (TANF, GA, SNAP, SSI OR FDPIR) |
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Name of State or Federal Public Assistance Program applicant is currently enrolled in: |
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Effective Dates of Eligibility |
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TANF GA |
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SSI (Supplemental Security Income) FDPIR |
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Please attach proof of enrollment in one of the qualifying Public Assistance Programs (TANF, GA, SNAP, SSI OR FDPIR). |
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PART D: |
IF YOU WERE PREVIOUSLY DETERMINED TO BE INDIGENT BY A NM COURT, PROBATION |
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& PAROLE OR TSD FOR PURPOSES OF INTERLOCK, COMPLETE PARTS C or D, & E |
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Was I determined to be indigent by TSD after 7/1/10? |
Yes No |
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Was I determined to be indigent by Court, Probation & Parole prior to 7/1/10? |
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Yes No |
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Date on Order: |
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Date Interlock Installed: |
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Ignition Interlock Provider / City: |
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Please attach a copy of your Judgement & Sentence if new DUI case. |
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If determined to be indigent for ignition interlock benefits prior to 7/1/10, attach a copy of your Order Determining Indigency. |
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PART E: |
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AGREEMENT, SIGNATURE AND NOTARIZATION |
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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.
I agree to notify the Division within ten (10) business days of any change to any information in this application. |
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By signing this form, I hereby acknowledge acceptance and understanding of the above statements. Additionally, I certify |
NOTARIAL |
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under penalties of perjury that all information in this Application is true, correct and complete to the best of my knowledge |
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and belief. |
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SEAL |
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Applicant Signature (Applicant signature must be notarized) |
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Date: |
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The foregoing instrument was acknowledged before me this _______ day of ___________ 20______ by _____________________. |
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Notary (Please print name) |
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My Commission Expires: __________________ |
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Notary Public Signature |
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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