The Texas DL-77 form is an application for a hardship driver license, designed to assist individuals who face unique challenges that prevent them from obtaining a standard license. This form allows applicants to explain their circumstances, such as economic hardship or family illness, and provides a pathway for those in need to gain driving privileges. Understanding the requirements and details of this application is crucial for anyone seeking this type of license in Texas.
The Texas DL-77 form serves a crucial purpose for individuals seeking a Hardship Driver License in the state of Texas. This application is designed for those who face unique circumstances that necessitate the issuance of a driver’s license despite not meeting standard eligibility requirements. Applicants may qualify based on several factors, including economic hardship that affects their family, medical needs of a family member, or enrollment in a vocational education program that requires driving. It is essential to complete the form accurately, as all information must be filled out in ink and submitted within a 90-day window. Once submitted, applicants should note that the Texas Department of Public Safety (DPS) does not provide refunds for application fees. The form gathers a variety of personal information, including the applicant's name, contact details, and medical history, while also inquiring about any health conditions that may impact driving abilities. Additionally, applicants must provide details regarding their family situation and the specific reasons for their hardship request. The form also includes sections for emergency contacts, vehicle registration, and optional donations to various causes. Understanding the requirements and implications of the DL-77 form is vital for those navigating the complexities of obtaining a Hardship Driver License in Texas.
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):
____ Red
____ 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: __________________________________________________________________________________________________________________________
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
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: ____________________________________________________________________________________________________________
Do you have a mental condition that may affect your ability to safely operate a motor vehicle? If yes, how? Please explain:
________________________________________________________________________________________________________________________________________________________________________
Have you ever had an epileptic seizure, convulsion, loss of consciousness, or other seizure?
Do you have diabetes requiring treatment by insulin?
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?
Within the past two years have you been treated for any other serious medical conditions? Please explain:
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
Do you own a motor vehicle that is required to be registered? (Texas Transportation Code section 502.040)
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:_______________________________________________________________
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:______________________________________
List all other members of the household: (Use extra page if necessary.)
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
ACID#
JUSTIFICATION /RESTRICTIONS:______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
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