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WAIVER OF HEARING
Division of Safety and Business Hearings
6 Empire State Plaza
Albany, NY 12228
Telephone No: (518) 474-1509
Fax: (518) 473-8505
Motorist’s Last Name
First Name M.I. Date of Birth (MM/DD/YYYY)
/ /
Motorist’s Address
Male Female
City State Zip Code
NYS Driver License/ID Number
If you wish to waive your right to a hearing for a chemical test refusal,
please fill out this waiver form and mail or fax it to the
above address as soon as you receive this notice. The effective date of your revocation will be the date your waiver is received by the
Division of Safety and Business Hearings (fax or postmark). In some cases this will make it possible to serve a period of
suspension/revocation at the same time as a suspension/revocation for the criminal charge of driving while intoxicated/ability impaired.
On ,I was arrested in the City Town Village
(Date)
of ,
in the County of , New York
by a member of
(Police Agency)
on a charge of operating a motor vehicle while under the influence of alcohol or drugs, in violation of Section 1192 of the Vehicle
and Traffic Law of the State of New York. It is alleged that I refused to submit to a chemical test as described in Section 1194 of
the Vehicle and Traffic Law. I was driving a motor vehicle with license plate number .
By signing this document, I waive my right to an administrative hearing by the Department of Motor Vehicles to decide if my
license should be revoked for my refusal to submit to a chemical test as described above.
Because of such refusal, I agree to
have my license (or driving privilege in New York State) revoked.
I agree that, if presented, the testimony of the arresting officer would establish all required elements to prove a refusal to submit
to a chemical test, as described in Section 1194 of the Vehicle and Traffic Law.
I understand that this means my license (or privilege of driving a motor vehicle in New York State) will be revoked. Before I may
be issued a new license or have my driving privilege restored, I must pay a $500 civil penalty required by law ($550 if I hold a
commercial driver license or was operating a commercial motor vehicle at the time of the offense).
I understand that a chemical test refusal will result in a driver responsibility assessment of $750, payable to DMV in three (3) annual
installments of $250. If I do not pay the assessment, DMV will suspend my driver license, learner permit, and/or driving privilege.
If this is my second chemical test refusal in five years, or if I have been convicted of a violation of any subdivision of Section 1192 of the
Vehicle and Traffic Law within the past five years, I must pay a $750 civil penalty before I may be issued a new license or have my
driving privilege restored. Multiple alcohol/drug incidents (3 or more) may result in permanent driver license/driving privilege revocation.
Signature of Motorist
(Sign Name in Full)
(Date)
AA-137W (1/17)
dmv.ny.gov
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