Fillable APPLICATION FOR TINTED WINDOW EXEMPTION Section 375(12-a)(b) of (New York State)

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APPLICATION FOR TINTED WINDOW EXEMPTION Section 375(12-a)(b) of (New York State)

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Page 1 of 2
APPLICATION FOR TINTED WINDOW EXEMPTION
Provide the following information as it appears on the vehicle registration.
If a medical exemption is requested for someone other than the registered owner of the vehicle, please provide the
following information about that person.
Section 375(12-a)(b) of the Vehicle and Traffic Law provides that the front windshield and side windows on both sides of any
eligible vehicle that is operated in New York State must allow at least 70% of any light to pass through. The rear window may
allow less than 70% of any light to pass through if the vehicle has mirrors on both sides that can be adjusted so the driver has a
clear view of the road and traffic conditions behind the vehicle. The rear side windows
of any station wagon, sedan, hardtop, coupe,
hatchback or convertible must also allow 70% of any light to pass through. A vehicle falls into one of these categories if it is labeled
“Passenger Car” on the Federal ID label found on the left front door panel.
The law provides an exemption for any person who, for medical reasons
, must be shielded from direct sunlight. The person who
requests an exemption may be either the driver or someone who is a regular passenger in the vehicle.
NYS Health Department regulations specify that
only certain medical conditions can be used to justify an exemption from the
limits on light transmittance. A list of these conditions is on page 2.
INSTRUCTIONS:
To request a medical exemption, send the following items to the address at the bottom of this page:
1. This completed application:
l Page 1 is to be completed by the requestor
l Page 2 must be completed by a physician, physician assistant or nurse practitioner
2. A photocopy of each NYS vehicle registration
*
Note: Based on the medical information submitted, our reviewer may ask for further medical details.
I certify and affirm that all information presented in this form is true and correct, that any documents, including supporting
documentation, that I have presented to DMV are true, accurate and genuine. I make this certification and affirmation under
penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal offense.
Signature of
Vehicle Registrant
X
(Sign Name in Full)
Last Name
Address (Number and Street)
City State Zip Code
First M.I.
Apt. #
Last Name
Address (Number and Street)
City State Zip Code
First M.I.
Apt. #
Return this application to: Department of Motor Vehicles, Driver Regulation Bureau, Medical Review Unit,
6 Empire State Plaza, Room 337, Albany NY 12228
MV-80W (1/19)
Date
Become an Organ Donor! Visit donatelife.ny.gov
dmv.ny.gov
MV-80W (1/19)
Page 2 of 2
PHYSICIAN’S STATEMENT FOR TINTED WINDOW EXEMPTION
This side must be completed by your physician/physician assistant/nurse practitioner.
/ /
1. Examination Date (Must be within one year from the date this form is submitted to the
Department of Motor Vehicles.)
2. The following medical conditions, when their existence is certified by a physician, physician assistant or nurse practitioner,
justify granting an exemption from the limits on light transmittance found in Vehicle and Traffic Law, section 375(12-a)(b),
provided that personal protective measures such as sun protective clothing, sunscreen, eye protective devices or clear UV-protective
window films, do not offer adequate protection. Check the medical condition that applies to the above-named patient:
albinism
chronic actinic dermatitis/actinic reticuloid
dermatomyositis
lupus erythematosus
porphyria
xeroderma (pigmentosa) pigmentosum
severe drug photosensitivity, provided that the course of treatment causing the photosensitivity is expected to be of
prolonged duration
photophobia associated with an ophthalmic or neurological disorder
any other condition or disorder causing severe
photosensitivity in which the individual is required for medical reasons to
be shielded from the direct rays of the sun. The medical condition of
warrants a tinted window exemption.
□
□
□
□
□
□
□
□
□
Physician/Physician Assistant/Nurse Practitioner’s Signature
Physician/Physician Assistant/Nurse Practitioner’s Name (Please print in full)
Physician/Physician Assistant/Nurse Practitioner’s Mailing Address (Include number and street)
City
Certificate or Professional License Number
State Where Licensed
Date (Month/Day/Year)
Based on my examination, tinted windows
are necessary for my patient’s health
/ /
I certify and affirm that all information presented in this form is true and correct, that any documents, including supporting
documentation, that I have presented to DMV are true, accurate and genuine. I make this certification and affirmation under
penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal offense.
PLEASE PRINT CLEARLY
□Yes
□No
State Zip Code
Telephone Number (area code)
□ Physician
□ Physician’s Assistant
□ Nurse Practitioner
( )
Patient’s Last Name First Name M.I.
Date of Birth
(Month/Day/Year)
/ /
□ Male □ Female
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APPLICATION FOR TINTED WINDOW EXEMPTION Section 375(12-a)(b) of (New York State)

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Completed 16 November 2020

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