Part D. Switch for Passenger Air Bag
I request authorization for the installation of an on-o switch for the passenger air bag in my vehicle. I certify that
I or another passenger in my vehicle meets the criteria for the risk group checked below. (At least one box must
be checked.)
Infant. I transport an infant (less than 1 year old) who must ride in the front seat because:
• My vehicle has no rear seat;
• My vehicle has a rear seat too small to accommodate a rear-facing infant seat; or
• e infant has a medical condition which, according to the infant’s physician, makes
it necessary for the infant to ride in the front seat so that the driver can constantly
monitor the child’s condition.
Child age 1 to 12. A child age 1 to 12 must ride in the front seat because:
• My vehicle has no rear seat;
• Although children ages 1 to 12 ride in the rear seat(s) whenever possible, children ages
1 to 12 sometimes must ride in the front because no space is available in the rear
seat(s) of my vehicle; or
• e child has a medical condition which, according to the child’s physician, makes
it necessary for the child to ride in the front seat so that the driver can constantly
monitor the child’s condition.
Medical condition. A passenger has a medical condition which, according to his or her physician:
• Causes the passenger air bag to pose a special risk for the passenger; and
• Makes the potential harm from the passenger air bag in a crash greater than the
potential harm from turning o that air bag and allowing the passenger, even if belted,
to hit the dashboard, or windshield in a crash.
Part E. I make this request based on the following certication and understandings
(check each box below after reading carefully):
Information brochure. I certify that I have read the NHTSA information brochure, Air Bags & On-O
Switches: Information for an Informed Decision. I understand that air bags should be turned o only for
people at risk and turned back on for people not at risk.
Loss of air bag protection. I understand that turning o an air bag may have serious safety consequences.
When an air bag is o, even belted people may hit their head, neck, or chest on the steering wheel,
dashboard, or windshield in a moderate to serious crash. at possibility may be increased in some newer
vehicles with seat belts that are specially designed to work with the air bag. ose belts, which are designed
to reduce the concentration of crash forces on any single part of the body, typically allow the occupant to
move farther forward in a crash than older belts. Without the air bag to cushion this forward movement, the
chance of the occupant hitting the vehicle interior is increased.
Waiver. I understand that motor vehicle dealers and repair businesses may require me to sign a waiver of
liability before they install an on-o switch.
Part F. Certication
I certify to the U.S. Department of Transportation that the information, certications, and understandings given or indicated by
me on this form are truthful, correct, and complete to the best of my knowledge and belief. I recognize that the statements I have
made on this form concern a matter within the jurisdiction of a department of the United States and that making a false, ctitious,
or fraudulent statement may render me subject to criminal prosecution under Title 18, United States Code, Section 1001.
Date Signature of owner/lessee
Additional instructions and information for vehicle owners and lessees: An owner or lessee of multiple vehicles (e.g., a eet owner) who
wants an on-o switch for the same air bag (e.g., just the passenger air bag) in more than one vehicle and for the same reason does not need
to submit a separate form for each vehicle. Instead, the owner or lessee may list the make, model, model year, and vehicle identication
number for each of those vehicles and attach the list to a copy of this form. Each page of the list must be signed and dated by the owner or
lessee. A list may also be attached to a single copy of this form if the owner or lessee wishes to request authorization for on-o switches for
both air bags in multiple vehicles.
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