Compliance and Safety-Interlock Installation Unit

P.O. Box 174

Trenton, New Jersey 08666-0174

Fax to 609-***-****

CERTIFICATION OF INTERLOCK COMPLIANCE-BASED REMOVAL OR NON-COMPLIANCE PRINT OR TYPE Driver Name (Last, First, Middle Initial) Brown,Kenya

New Jersey Driver License Number

NJ B76104326609822

Mailing Address

251 Meeker Ave

City

Newark

County

ESSEX

State

NJ

Zip Code

07112

Vehicle Make/Model

HONDA Accord

Year

2013

Vehicle Identification Number (VIN)

1HGCR2F33DA255162

License Plate Number

NJ B74HUC

Offense Date:

12/26/2021

Court-Ordered Installation Period:

3 Months

Date of Installation:

10/20/2022

Total Number of Days Installed:

129

Last Day of Court-Ordered Installation Period:

1/21/2023

Compliant (All three boxes below MUST be checked for Interlock Compliance) During the final 30 days of the court-ordered installation period, there has been no more than one failure to take a test; and During the final 30 days of the court-ordered installation period, there has been no more than one failure to pass a test with a breath alcohol concentration (BAC) of 0.08% or higher (unless a re-test conducted within five minutes of the initial test indicated a BAC of less than 0.08%); and

During the court-ordered installation period, the person has complied with all maintenance, repair, calibration, monitoring, and inspection requirements of the device.

Court Order Compliance achieved after previous review of non-compliance. (Attach Court Order with signature of the Judge) Non-Compliance: For NJ offenses: This form must be sent to the NJ sentencing court and the New Jersey Motor Vehicle Commission. For Out-of-State offenses: This form must be sent to the New Jersey Motor Vehicle Commission ONLY. Non-Compliant

During the final 30 days of the court-ordered installation period, there has been more than one failure to take a test; or During the final 30 days of the court-ordered installation period, there has been more than one failure to pass a test with a breath alcohol concentration (BAC) of lower than 0.08% (and there was no re-test conducted within five minutes of the initial test indicating a BAC of less than 0.08%); or

During the court-ordered installation period, the person has failed to appear at the ignition interlock provider when required for maintenance, repair, calibration, monitoring, or inspection of the device. INTERLOCK PROVIDER MUST ATTACH REPORT OF NON-COMPLIANCE WITH THIS FORM. Court Name

Passaic County Superior Court- NJ

Address

77 Hamilton St

City and Zip Code

Paterson, NJ 07505

Provider/Installer

I certify that the information provided on this form is true and correct. I am aware that if any of the information provided on this form is false, I am subject to penalty pursuant to N.J.S.A. 2C:21-3, 2C:21-4, N.J.A.C. 13:19-6.1 et seq.

Best Labs 1A Smart Start, Inc. LifeSafer

Guardian Interlock Systems Alcohol Detection Systems Intoxalock

Low Cost Interlock, Inc. Draeger, Inc. Simple Interlock PRINT OR TYPE Ignition Interlock Service Center

NJ Interlock Mobil Service

New Jersey Business License Number

000168

Device Serial Number

1C485654

Name of Company Representative Authorized to Complete This Form (Area Code) Telephone Number

877-***-****

Mailing Address

111035 Aurora Avenue

City

Urbandale

State

Iowa

Zip Code

50322

Signature Date of Compliance Review

Revised 2/20

Drey Blevins

Contact this candidate