Application For Exemption To The Window Tint Law Form

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STATE OF GEORGIA

DEPARTMENT OF PUBLIC SAFETY

APPLICATION FOR EXEMPTION TO THE WINDOW TINT LAW

Official Code of Georgia Annotated (OCGA) Section 40-8-73.1 prohibits the use of tinted windows with certain exceptions. One exception allows persons with a

restrictive medical condition to operate or ride in a vehicle with tinted windows.

When approved by the Department of Public Safety, the approval copy of this completed document serves as authorization for exemption to the window tint law

based on a restrictive medical condition. Each application must have an attestation from a person licensed to practice medicine under Chapter 34 of Title 43 or a

person certified as an optometrist under Chapter 30 of Title 43.

A $10 fee per application/household is required. All funds must be paid by either money order, certified check, or cashier’s check. No personal checks will be

accepted. Return this form along with the required fee to the Department of Public Safety, Attention: Accounts Receivable, P.O. Box 1456, Atlanta, GA 30371-2303.

For any questions concerning this permit, please call (404)624-7751.

APPLICANT INFORMATION

Name: __________________________________________________________________

Date of Birth: ____________________________________

Mailing Address: __________________________________________________________

Driver’s License No.: _______________________________

City, State & Zip: ___________________________________________________________

Phone No: ______________________________________

If Applicant is under the age of 19, signature of parent/guardian: ___________________________________________________________________________

Owner of vehicle (may be different than the above applicant):

First

Middle

Last

D.O.B

VEHICLE(S) DATA

Year

Make

Vehicle Identification Number

License Plate Number

Note: This is an official document of the Department of Public Safety and signing this form verifies the information provided is true and correct. It is a felony to

knowingly make any false or fictitious statement or entry on this form. If any such statement or entry is made the signatory will be subject to criminal prosecution

under the laws of this state including, but not limited to OCGA 16-10-20.

ATTESTATION

I have personally examined the above applicant or habitual passenger and find that he/she suffers from (state medical reason):_____________________________

_______________________________________________________________________________________________________________________________________

and, as a result of said medical reasons, is required to be shielded from the direct rays of the sun, and for which eye protective devices will not provide adequate

protection.

Note: Physician’s Assistants, Nurse Practitioners, Registered Nurses, and LPNs are not authorized to sign this form.

____________________________________________________________________

Typed or Printed Name of Physician/Optometrist:

(Circle One)

Georgia State License Number: _______________________________________ Physician/Optometrist Phone #: ___________________________________________

Physician/Optometrist Signature: _______________________________________________________________

Date: _____________________________

(Circle One)

Vehicle Owner Signature: _____________________________________________________________________

Date: _____________________________

Habitual Occupant Signature: __________________________________________________________________

Date: _____________________________

This letter of exemption is valid for a period of four years from the approval date below and must be carried at all times in the vehicle described above. If the

vehicle is sold, this waiver is not transferable, and this letter must be returned to the Department of Public Safety at the above address.

Signature of DPS Official: ______________________________________________________________________

Date: _____________________________

Note: 1. Nothing herein shall allow tinting of a windshield; 2. No tinting of window below 23% light transmission; 3. See attached Rules & Regulations.