Data Entry Customer Service

***-**** (**/****)

OREGON IGNITION INTERLOCK DEVICE

OVERSIGHT PROGRAM

NO NEGATIVE CERTIFICATE

Instructions for filling out:

Diversion: If the individual intends to motion the court for early termination of the IID requirement as a condition of a DUI Diversion Agreement.

Send the Six-Month No Negative Certificate to:

• Individual

• OSP IID Program: Email to

******.***.******@***.******.***

• Individual

• OSP IID Program: Email to

******.***.******@***.******.***

For court information, go to Oregon.gov and search "Courts."

*Fields in this form may be completed electronically. DMV Driver Suspension Unit: 1905 Lana Ave. NE, Salem, OR 97314 or email to ********@****.*****.**.**

Section 1 – IID Required Driver Information

NAME (FIRST, MIDDLE, LAST) DATE OF BIRTH (MM/DD/YYYY) DRIVER LICENSE ADDRESS (STREET, CITY, STATE) EMAIL (REQUIRED)

DIVERSION CONVICTION

CASE NUMBER (DIVERSION ONLY)

Section 2 – Manufacturer’s Representative Information IID COMPANY NAME PHONE

Section 3 – No Negative Report

SIX CONSECUTIVE MONTHS (EARLY REMOVAL) 90 CONSECUTIVE DAYS Section 3A – Six Consecutive Months (Diversion Only) Pursuant to Oregon Revised Statute (ORS) 813.645, I certify that the individual’s device(s) did not record a violation in accordance with ORS 813.599, and has had no negative reports for the last six consecutive months, between the dates of: and . Section 3B – 90 Consecutive Days (DMV Only)

Pursuant to Oregon Revised Statute (ORS) 813.635, I certify that the individual’s device(s) did not record a violation in accordance with ORS 813.599, and has had no negative reports for the last 90 consecutive days, between the dates of: and . Under penalty of perjury, I certify and declare that all of the information provided above is true, correct, accurate and complete to the best of my knowledge.

AUTHORIZED REPORTING REPRESENTATIVE PRINT NAME AUTHORIZED REPORTING REPRESENTATIVE SIGNATURE DATE Section 4 – OSP Use Only

Pursuant to Oregon Administrative Rule (OAR) 257-***-****, OSP will review all No Negative Certificates for accuracy and Ignition Interlock Device Program compliance in accordance with ORS Chapter 813. REVIEWER NAME REVIEWER SIGNATURE OFFICE/REGION DATE Conviction: To end an IID requirement, Oregon DMV must receive a certificate from the Manufacturer’s Representative certifying that the individual has had no IID Negative Reports in the last 90 consecutive days of their requirement. Send the 90-Day No Negative Certificate to:

DATE NNR REQUESTED

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