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Blank Texas Vi 4 PDF Template

The Texas Vi 4 form serves as an application for a medical exemption related to window tint regulations in vehicles. This form is essential for individuals seeking to legally tint their vehicle windows beyond the standard limits due to medical conditions. Proper completion and submission of this form, along with required documentation, can facilitate the approval process for the exemption.

Open Form

Contents

Form Example

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)	Relationship to Applicant
	(IF DIFFERENT FROM APPLICANT)

Residence	City	State	County	ZIP
Address	City	State	County	ZIP
Address

Mailing	City	State	County	ZIP
Mailing
Address
Address

Date of Birth

Home Phone	Cell Phone
Business Phone	Other Phone

VEHICLE INFORMATION

Vehicle #1

VIN

Year

Make

Model

VEHICLE #2

VIN

Year

Make

Model

VEHICLE #3

VIN

Year

Make

Model

PHYSICIAN, OPTOMETRIST OR OPHTHALMOLOGIST

Name

Address

		License #

	City	State	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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Common mistakes

Failing to use the most current version of the Texas VI 4 form can lead to delays or denials. Always check the Texas Department of Public Safety website for updates.
Not typing the application can result in unclear handwriting, making it difficult for officials to read the information. The form must be typed to ensure clarity.
Incorrectly entering personal information, such as the applicant's name or driver's license number, can cause significant issues. Ensure that the name matches exactly as it appears on the driver's license.
Omitting the relationship to the patient when it differs from the applicant can lead to confusion. This information is crucial for processing the application correctly.
Not providing complete vehicle information for all applicable vehicles can delay the application. Each vehicle's VIN, year, make, and model must be included.
Neglecting to include the physician’s or optometrist’s contact details can hinder the verification process. Make sure to provide their name, address, email, and phone number.
Failing to attach the required documentation, such as a signed letter or prescription from a physician, can result in an incomplete application. Ensure that these documents are dated within one year of the exemption request.
Not signing and dating the certification statement can invalidate the application. This affirmation is critical, as it confirms the truthfulness of the information provided.

Key takeaways

Here are some key takeaways about filling out and using the Texas Vi 4 form:

Use the most current form. Always ensure you are using the latest version of the Texas Vi 4 form to avoid any issues.
Type your information. The form must be filled out using a computer or typewriter to ensure clarity.
Provide accurate personal details. Include your name, driver’s license number, and contact information exactly as they appear on your driver’s license.
Include vehicle information. You can list up to three vehicles. Make sure to provide the correct VIN, year, make, and model for each vehicle.
Attach required documentation. Submit a letter from your physician or an original prescription that states the medical reason for your exemption.
Submit your application correctly. You can send the completed form via secured email, fax, or by mail to the Texas Department of Public Safety.
Be patient after submission. Allow up to 15 working days for processing and approval of your application.

⇓ Texas Vi 4 PDF

Steps to Using Texas Vi 4

Completing the Texas Vi 4 form is an essential step for those seeking a medical exemption for window tint on vehicles. After submitting the form, the Texas Department of Public Safety will review your application. If approved, you will receive an exemption letter at the address provided.

Obtain the Most Current Form: Visit the Texas Department of Public Safety website to download or print the latest version of the Texas Vi 4 form.
Fill Out Applicant Information: Enter your name as it appears on your driver’s license, along with your driver’s license number, state, and expiration date.
Provide Patient Information: If the patient is different from the applicant, include their name and your relationship to them.
Complete Residence Information: Fill in your residence address, including city, state, county, and ZIP code.
Enter Mailing Address: If different from your residence, provide your mailing address, including city, state, county, and ZIP code.
Input Date of Birth: Enter your date of birth in the designated field.
Include Contact Information: Provide your email address and phone numbers (home, cell, business, and any other relevant phone number).
Detail Vehicle Information: For up to three vehicles, list the VIN, year, make, and model of each vehicle.
Physician Information: Fill in the name, address, email, license number, city, state, ZIP code, phone, and fax number of your physician, optometrist, or ophthalmologist.
Certification: Read the certification statement carefully. Sign and date the application to affirm that all information is accurate.
Gather Supporting Documentation: Include a letter from your physician on official letterhead or an original prescription that states the medical reason for the exemption, ensuring it is dated within the last year.
Submit Your Application: Send the completed form and required documentation via one of the following methods:
- Online secured email through the Texas DPS website.
- Fax to (512) 424-2774.
- Mail to: Texas Department of Public Safety, Regulatory Services Division, Compliance & Enforcement Service, Window Tint Medical Exemption, P.O. Box 4087, Austin, Texas 78773-0543.
Wait for Processing: Allow up to 15 working days for your application to be processed and to receive your exemption certificate.