Ignition Interlock Indigent Form

Ignition Interlock Indigent Form Source: Miss. Code Ann. § 45-1-3 Mississippi Department of Public Safety Ignition Interlock Indigent Form Program Participant: Please Print First Name: __________________Middle Name: _____________Last Name: ____________ Address:_________________________City:_______________State:________Zip:___________ Home Phone: _________________Work Phone: __________________ Employer: _____________________Address:__________________________________ Driver’s License Number: _______________________Date of Birth: ______________________ Indigence is determined based on proof of enrollment in one or more of the following types of assistance: Check applicable items and attach appropriate documentation. 9. Temporary Assistance for Needy Families, TANF □ 10. Medicaid assistance □ 11. The Supplemental Nutritional Assistance Program, SNAP □ 12. Supplemental security income, SSI □ 13. Participation in a federal food distribution □ 14. Federal housing assistance □ 15. Unemployment compensation □ 16. Other criteria approved by the Mississippi Department of Public Safety □ Part 505 Chapter 12 Ignition Interlock Installation Form