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Blank Texas From Dl 77 PDF Template

The Texas DL-77 form is an application for a Hardship Driver License, designed for individuals who face unique challenges that prevent them from obtaining a standard license. This form allows the Texas Department of Public Safety to evaluate requests based on specific circumstances, such as economic hardship or family health issues. Understanding the requirements and process for this application can help applicants navigate their options effectively.

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Contents

Form Example

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):

____ Black

____ Red

____ Gray

____ Brown

____ 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: __________________________________________________________________________________________________________________________

City:_______________________________________________________ State: _______ Zip Code:____________ County: _______________________________________

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

YES NO

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: ____________________________________________________________________________________________________________

2.	___	___	Do you have a mental condition that may affect your ability to safely operate a motor vehicle? If yes, how? Please explain:
			________________________________________________________________________________________________________________________________________________________________________
3.	___	___	Have you ever had an epileptic seizure, convulsion, loss of consciousness, or other seizure?
4.	___	___	Do you have diabetes requiring treatment by insulin?
5.	___	___	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?
6.	___	___	Within the past two years have you been treated for any other serious medical conditions? Please explain:
			________________________________________________________________________________________________________________________________________________________________________
7.	___	___	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
1.	___	___	Do you own a motor vehicle that is required to be registered? (Texas Transportation Code section 502.040)
2.	___	___	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:_______________________________________________________________		Phone Number: ____________________________________________________
	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:______________________________________

Employed by:______________________________________ Address: _______________________________________________________________________________________฀

Work Hours:______________________________________ Work Phone:______________________________________

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	Date	ACID#

JUSTIFICATION /RESTRICTIONS:______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

DL-77 (Rev. 7/2020)

Use extra page if necessary.

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Common mistakes

Using the wrong writing instrument: The form must be filled out in ink. Using pencil or any other writing tool can lead to rejection of the application.
Leaving required fields blank: Every section marked as required must be completed. Omitting information can delay processing or result in denial.
Inaccurate personal information: Ensure that names, dates, and other personal details are correct. Mistakes can lead to confusion and complications.
Failing to sign the application: The applicant's signature is necessary. Without it, the application is incomplete and cannot be processed.
Not providing emergency contacts: If applicable, include up to two emergency contacts. Missing this information may hinder assistance in emergencies.
Ignoring medical history questions: All medical questions must be answered honestly. Failing to disclose relevant information could lead to safety issues.
Incorrect donation amounts: If choosing to make donations, ensure the amounts are clearly written and accurate. Ambiguities can cause processing issues.
Not including supporting documentation: If applying under specific hardship provisions, required documents must be attached. Applications lacking necessary documentation may be rejected.

Key takeaways

Complete the Form in Ink: When filling out the Texas DL-77 form, ensure that all information is written in ink. This requirement helps maintain the clarity and legibility of your application.
Understand the Hardship License Criteria: A hardship driver license may be granted if the applicant can demonstrate that not receiving the license would create an unusual economic hardship, is necessary due to a family member's illness, or is required for participation in a vocational education program.
Emergency Contact Information: The form allows applicants to provide up to two emergency contacts. This step is crucial for ensuring that someone can be reached in case of injury or death.
Be Aware of Application Validity: Once submitted, the application is held for only 90 days. It's important to act promptly, as the Texas Department of Public Safety cannot refund any payments made after submission.

⇓ Texas From Dl 77 PDF

Steps to Using Texas From Dl 77

Filling out the Texas Form DL-77 is a crucial step for those seeking a hardship driver license. After completing this form, you'll submit it to the Texas Department of Public Safety (DPS) for review. Ensure that all information is accurate and complete, as incomplete applications may delay the process.

Gather Necessary Information: Before starting, collect all required personal details such as your full name, date of birth, and contact information.
Complete Applicant Information: Fill in your last name, first name, middle name, and suffix. Include your birth surname, Social Security Number (SSN), date of birth, sex, height, weight, eye color, hair color, race, and ethnicity.
Provide Place of Birth: Indicate the city, state, county, and country of your birth.
List Parent Information: Write down your father's last name and your mother's maiden name.
Fill Out Contact Information: Provide your residence and mailing addresses, including city, state, zip code, county, home phone, other phone, and email.
Emergency Contacts: If desired, list up to two emergency contacts, including their names, phone numbers, and addresses.
Answer Required Questions: Go through the required questions about citizenship, health conditions, and donations, marking 'yes' or 'no' as applicable.
Complete Medical History Questions: Answer the medical history questions truthfully, explaining any conditions that may affect your driving.
Provide Vehicle Registration and Insurance Information: Indicate whether you own a motor vehicle that needs registration and insurance.
Select Hardship Provision: Choose the reason for your hardship license application and provide any necessary details or documentation.
List Household Members: Include all other members of your household, their license numbers, and relationships to you.
Explain Driving Necessities: Describe why you need to drive and why others cannot perform this function.
Acknowledge Receipt of Educational Information: Sign to confirm you received the educational information regarding state laws related to driving.
Parental Authorization: If you are a minor, ensure your parent or guardian signs the parental authorization section.
Review and Submit: Double-check all entries for accuracy, sign where required, and submit the form to the DPS.