Texas From Dl 77 Form PDF Details

In the state of Texas, the journey towards obtaining a driver's license can be punctuated by various hurdles, and for some, these are compounded by specific, pressing needs—circumstances that the Texas Department of Public Safety has sought to address through the issuance of a Hardship Driver License. The DL-77 form stands as a critical application for those seeking such a license, catering specifically to applicants facing unusual economic hardships, those with sick family members requiring transportation, or individuals in vocational educational programs in dire need of driving privileges to continue their education or employment. This meticulously designed form requires detailed personal information, including evidence of citizenship, medical history to ensure safe driving capabilities, and a record of any previous attempts to secure a hardship license. Moreover, it entails a section for parental authorization, a testament to its inclusive design primarily aimed at minors under 18, alongside options for organ donation and contributions to charitable causes, making it a document that not only facilitates a critical need for mobility but also encourages civic responsibility. The complexity and thoroughness of the DL-77 form underscore the Texas Department of Public Safety's commitment to balancing road safety with the genuine needs of its residents, marking it as an essential tool for individuals and families navigating the challenges of obtaining driving privileges under extraordinary circumstances.

QuestionAnswer
Form NameTexas From Dl 77 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesDL 77 content form

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DL-77 - TEXAS HARDSHIP DRIVER LICENSE CARD APPLICATION

NOTICE: All information on this application must be in INK. Applications held for 90 days only.

DPS CANNOT REFUND PAYMENT ONCE APPLICATION IS SUBMITTED.

FOR DEPARTMENT USE ONLY

Class (select one):____C ____M

ASSIGNED # _______________________

The Texas Department of Public Safety may issue a driver license to a person who complies with the requirements for the Hardship License if (1) the failure or refusal to issue the license will result in an unusual economic hardship for the family of the applicant, (2) the license is necessary because of the illness of a member of the applicant’s family, or (3) a license is necessary because the applicant is enrolled in a vocational education program and requires a driver’s license to participate in the program. The completion of an approved course in driver education is required. Texas Transportation Code 521.223 and 521.224

APPLICANT INFORMATION

Last Name:_________________________________________ First Name:_________________________________________ Middle Name: ___________________________

Suffix:__________________________________ Birth Surname

( Maiden):_________________________________________

 

-

-

SSN:________________________________

Date of Birth (mm/dd/yyyy):_____________________

Sex (select one): ___ Male

___ Female

Height: ______ Ft.

______ In.

Weight: __________ Lbs.

Eye Color (select one): ____ Blue

____ Brown

____ Gray

____ Hazel

____ Green

____ Black

____ Maroon

____ Pink

 

 

Hair Color (select one):

____ Black

____ Red

____ Gray

____ Brown

____ Blonde

____ Bald

____ White

 

 

 

Race (select one): ____ (AI) Alaskan or American Indian

____ (AP) Asian or Pacific Islander

____ (BK) Black

____ (W) White

 

 

Ethnicity (select one):

____ (H) Hispanic Origin

____ (O) Not of Hispanic Origin ____ (U) Unknown

 

 

 

Place of birth: City:_______________________________________

State: _____

County:________________________ Country: ___________________________________________

Father’s Last Name:_________________________________________________________

Mother’s Maiden Name: ____________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residence Address:_______________________________________________________________________________________________________________________

City:_______________________________________________________ State: _______ Zip Code:____________ County: _______________________________________

Mailing Address: __________________________________________________________________________________________________________________________

City:_______________________________________________________ State: _______ Zip Code:____________ County: _______________________________________

Home Phone:________________________ Other Phone:________________________ Email: _____________________________________________________________

In the event of injury or death would you like to provide up to two (2) emergency contacts? If yes, please list:

a)Name ____________________________________ Phone Number __________________ Address _________________________________________________________

b)Name ____________________________________ Phone Number __________________ Address _________________________________________________________

REQUIRED INFORMATION FROM ALL APPLICANTS

YES NO

1.

___

___

Are you a citizen of the United States?

2.

___

___

Do you have a health condition that may impede communication with a peace officer? (physician must complete form DL-101).

3.

___

___

Would you like to register as an organ donor?

4.

___

___

Do you want to donate $1.00 to the Blindness Education Screening and Treatment Program?

5.

___

___

Do you want to support the Glenda Dawson Donate Life Texas donor registry? If yes, please indicate a donation amount of $1 or more

 

 

 

$_______.00.

6.

___

___

Do you want to support Texas Veterans? If yes, please indicate a donation amount of $1 or more $_________.00.

7.

___

___

Do you want to support survivors of sexual assault? If yes, please indicate a donation amount of $1 or more $_________.00 to help fund the testing

 

 

 

of sexual assault evidence collection kits (rape kits).

8.

___

___

Do you want to support the issuance of a DL/ID for foster or homeless youth? If yes, please indicate a donation amount of $1 or more

 

 

 

$_________.00 to exempt this population from paying any fees.

REQUIRED INFORMATION FROM DRIVER LICENSE APPLICANTS ONLY (FOR CONFIDENTIAL USE OF THE DEPARTMENT ONLY)

MEDICAL HISTORY QUESTIONS

YES NO

1. ___ ___ Do you currently have or have you ever been diagnosed with or treated for any medical condition that may affect your ability to safely operate a motor vehicle? Examples, including but not limited to: Diagnosis or treatment for heart trouble, stroke, hemorrhage or clots, high blood pressure, emphysema (within the past two years) • progressive eye disorder or injury (i.e., glaucoma, macular degeneration, etc.) • loss of normal use of hand, arm, foot or leg • blackouts, seizures, loss of consciousness or body control (within the past two years) • difficulty turning head from side to side • loss of muscular control

•stiff joints or neck • inadequate hand/eye coordination • medical condition that affects your judgment • dizziness or balance problems • missing limbs Please explain and identify your medical condition: ____________________________________________________________________________________________________________

2.

___

___

Do you have a mental condition that may affect your ability to safely operate a motor vehicle? If yes, how? Please explain:

 

 

 

________________________________________________________________________________________________________________________________________________________________________

3.

___

___

Have you ever had an epileptic seizure, convulsion, loss of consciousness, or other seizure?

4.

___

___

Do you have diabetes requiring treatment by insulin?

5.

___

___

Do you have any alcohol or drug dependencies that may affect your ability to safely operate a motor vehicle or have you had any episodes of

 

 

 

alcohol or drug abuse within the past two years?

6.

___

___

Within the past two years have you been treated for any other serious medical conditions? Please explain:

 

 

 

________________________________________________________________________________________________________________________________________________________________________

7.

___

___

Have you EVER been referred to the Texas Medical Advisory Board for Driver Licensing?

DL-77 (Rev. 7/2020)

APPLICATION CONTINUED ON BACK

VEHICLE REGISTRATION AND INSURANCE INFORMATION

1.

___

___

Do you own a motor vehicle that is required to be registered? (Texas Transportation Code section 502.040)

2.

___

___

Do you own a motor vehicle that is required to have liability insurance OR other proof of financial responsibility in compliance with the Motor

 

 

 

Vehicle Safety Responsibility Act? (Texas Transportation Code section 601.051)

 

 

 

 

 

APPLICANT IS APPLYING FOR A HARDSHIP DRIVER LICENSE UNDER THE FOLLOWING PROVISION(S):

____ 1.

An unusual economic hardship on the family of the minor.

 

____ 2.

A death-related emergency: Name of Deceased: ______________________________________________________________________________________________

 

Date of Death:________________

Relationship to Deceased: _________________________________________________________________________________

____ 3.

Sickness or illness or disability of family members (PHYSICIAN’S STATEMENT REQUIRED)

 

Name of Family Member:_______________________________________________

Relationship:_______________________________________________________

 

Family Physician:______________________________________________________

Phone Number: ____________________________________________________

____ 4.

Enrollment in a Vocational Education Program (CERTIFICATION FROM SCHOOL REQUIRED)

 

School:_______________________________________________________________

Phone Number: ____________________________________________________

 

Address of School:____________________________________________________

City: ______________________________________________________________

Time Classes: Start:______________ End:______________

Days: ___ MON

___ TUES

___ WED ___ THUR ___ FRI ___ SAT ___ SUN

 

 

 

 

ADDITIONAL INFORMATION

 

 

 

Does the applicant have a Texas Learner License, Provisional license or ID card? ___ YES

___ NO

If YES, # _____________________________________________฀

Has the applicant ever applied for a Hardship Driver License? ___ YES ___ NO Where? ________________________________________________________________฀

Has the applicant completed a required driver education course? ___ YES ___ NO (Choose one) ___ Classroom ___ Driving ___ Both

FATHER’S NAME:___________________________________________________________ License Number:______________________________________

Employed by:______________________________________ Address: _______________________________________________________________________________________฀

Work Hours:______________________________________ Work Phone:______________________________________

MOTHER’S NAME:___________________________________________________________ License Number:______________________________________

Employed by:______________________________________ Address: _______________________________________________________________________________________฀

Work Hours:______________________________________ Work Phone:______________________________________

List all other members of the household: (Use extra page if necessary.)

Name:______________________________________________________ License #:________________________________ Relationship: ______________________________

Name:______________________________________________________ License #:________________________________ Relationship: ______________________________

Name:______________________________________________________ License #:________________________________ Relationship: ______________________________

Explain all necessary driving of applicant and why others cannot perform this function: NOTE: TRAVEL TO PARTICIPATE IN SCHOOL ACTIVITIES SUCH AS BAND,

SPORTS, ETC., WILL NOT BE CONSIDERED A SUFFICIENT REASON TO ESTABLISH AN UNUSUAL ECONOMIC HARDSHIP. (TAC Title 37 §15.28)

Use extra page if necessary.

Texas law requires the Texas Department of Public Safety to provide every minor applicant (under age 18) and cosigner, for a driver license in Texas, educational information concerning state laws relating to distracted driving, driving while intoxicated, driving by a minor with alcohol in the minor’s system, and the implied consent law. The minor applicant and cosigner must acknowledge receipt of this information prior to issuance of any driver license or permit.

I hereby acknowledge receipt of this information.

_______________________________________________________________

_______________________________________________________________

__________________________

Minor Applicant

Parent/Legal Guardian

Date of Receipt

PARENTAL AUTHORIZATION

TO THE PARENT: In making this application as parent or guardian of _________________________________________________________________ ,

I take full responsibility for the authorization of said minor to be issued a driver license. I understand that the Department may make any investigation necessary to confirm or deny any information contained in this application or information concerning early enrollment authority in a driver education course as provided in Texas Transportation Code section 521.223.

_______________________________________________________________

_________________________________________

__________________________

Usual Written Signature of Parent or Guardian

Driver License Number

Date

NOTICE: The information on this application is required by the Texas Driver License Act, Texas Transportation Code Chapter 521. Failure to provide the information is cause for refusal to issue a driver license or identification card, and in some cases, cancellation or withdrawal of driving privileges. False information could also lead to criminal charges with penalties of a fine up to $4,000.00 and/or jail.

SOCIAL SECURITY NUMBER COLLECTION DISCLOSURE

Disclosure of your social security account number is mandatory for identification card and driver license applicants, but voluntary for election identification certificate applicants. This information is solicited pursuant to 42 U.S.C. section 405(c)(2)(C)(i), 42 U.S.C. section 666(a)(13)(A), 6 C.F.R. section 37.11(e), 49 C.F.R. section 383.153, Texas Family Code section 231.302(c)(1), and Texas Transportation Code sections 521.142 and 522.021. The Department will use social security number information for identification purposes and will only release the number as statutorily authorized by Texas Transportation Code section 521.044.

DO NOT WRITE BELOW THIS LINE – FOR DEPARTMENT USE ONLY

Application (Select one): ___ Approved ___ Rejected _____________________________________________________________

________________

_________________

Signature

Date

ACID#

JUSTIFICATION /RESTRICTIONS:______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

DL-77 (Rev. 7/2020)

Use extra page if necessary.

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APPLICATION CONTINUED ON BACK, DL Rev, and Have you EVER been referred to inside Texas From Dl 77 Form

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