The Texas Vi 4 form is an application used to request a medical exemption for window tint on vehicles. This form must be completed and submitted to the Texas Department of Public Safety to ensure compliance with state regulations regarding vehicle window tinting. Proper documentation, including a physician's letter or prescription, is required to support the exemption request.
The Texas Vi 4 form serves as a crucial document for individuals seeking a medical exemption for window tint on their vehicles. This form, mandated by the Texas Department of Public Safety, must be completed in a typed format to ensure clarity and accuracy. Applicants are required to provide personal information, including their driver's license number, contact details, and the names of any patients related to the exemption request. The form also requires detailed vehicle information for up to three vehicles, including the Vehicle Identification Number (VIN), make, model, and year. In addition, a licensed physician, optometrist, or ophthalmologist must validate the medical necessity for the exemption by providing a signed letter or an original prescription, both of which must be dated within the past year. The applicant certifies the truthfulness of the information provided under penalty of perjury, emphasizing the importance of accuracy in this process. Once completed, the form can be submitted through various channels, including online, fax, or traditional mail. Applicants should anticipate a processing time of up to 15 working days to receive their exemption certificate if approved.
Texas Department of Public Safety Regulatory Services Division www.dps.texas.gov
MUST USE MOST CURRENT FORM
FORM MUST BE TYPED
VEHICLE INSPECTION WINDOW TINT
FOR DPS USE ONLY
APPLICATION FOR WINDOW TINT MEDICAL EXEMPTION
APPLICANT (PLEASE USE NAME AS IT APPEARS ON DRIVER LICENSE)
Name
DL #
State
Expiration
Patient Name
Relationship to Applicant
(IF DIFFERENT FROM APPLICANT)
Residence
City
County
ZIP
Address
Mailing
Date of Birth
Email
Home Phone
Cell Phone
Business Phone
Other Phone
VEHICLE INFORMATION
Vehicle #1
VIN
Year
Make
Model
VEHICLE #2
VEHICLE #3
PHYSICIAN, OPTOMETRIST OR OPHTHALMOLOGIST
License #
Zip
Phone
Fax
Vehicle Owner Certiication
I certify and afirm that all information presented in this form is true and correct, that any documents I have presented to DPS are genuine, and that the information included in all supporting documentation is true and accurate. I make this certiication and afirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
Applicant / Legal Guardian’s Signature
Date
Completed application must be accompanied by one of the following:
●Letter, on physician letterhead, signed by the physician, indicating the medical reason for the exemption.
●An original prescription including the applicant’s name, physician’s signature and indicating the medical reason for the exemption.
Letters and prescriptions must be dated within one year of exemption request. If the exemption is approved, an exemption letter will be sent to the applicant listed above.
SUBMIT completed form with required documentation:
●Online Secured Email
➢Contact Us, select “Vehicle Inspection” and complete the online form.
➢http://www.txdps.state.tx.us/rsd/contact/default.aspx
●Fax to (512) 424-2774
●Mailing Address: Texas Department of Public Safety
Regulatory Services Division, Compliance & Enforcement Service
Window Tint Medical Exemption
P. O. Box 4087
Austin, Texas 78773-0543
Please allow up to 15 working days for your application to be processed, approved and to receive your exemption certiicate.
VI-4 (Rev. 3/16)
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