Department of Taxation and Finance

                               Application for Undue Economic                                                         DTF-5.1(7/19)
                               Hardship Exemption from Driver’s 
                               License Suspension Program

Form DTF-5, Statement of Financial Condition, must accompany this application. You must answer all questions and provide all 
required attachments listed on Form DTF-5, page 10.

 1.  Taxpayer information
Taxpayer name                                                                                   Social Security number

Spouse’s name                                                                                   Spouse’s Social Security number

Physical home address                                                                           Telephone number

Mailing address (if different from above, or if a PO box number)

Taxpayer representative’s name (attach power of attorney; see instructions)                     Telephone number

Taxpayer representative’s address

Justificationforexemption
Provide the facts and reasons supporting how the suspension would cause undue economic hardship (see instructions). If you have 
attempted to obtain a restricted-use license, explain the status of that application.

 3.  Signature
Under penalties of perjury, I declare that I have examined this application, I have enclosed Form DTF-5 and all required documents, 
and to the best of my knowledge it is true, correct, and complete. 
I make these statements with the knowledge that willfully providing false or fraudulent information in this application may constitute a 
felony or other crime under New York State Law, punishable by a fine and/or jail.
I understand that the Tax Department is authorized to investigate the validity and the accuracy of any information entered on this 
document and may request additional information or documentation in connection with this application.

Date                                                                        Taxpayer’s signature

Date                                                                        Spouse’s signature

Page 2 of 2   DTF-5.1 (7/19)

General instructions                                         More information
Use this form to request an exemption from the Driver’s      For questions, call 518-862-6000. For forms and more 
License Suspension Program based on undue economic           information, see www.tax.ny.gov.
hardship. All requests for exemption must include a 
completed Form DTF-5, Statement of Financial Condition ,     Your rights as a taxpayer
available at www.tax.ny.gov, including copies of:            For a full explanation of your rights as a taxpayer, 
• your last three year’s federal income tax returns,         including your rights in the collection process and how to 
                                                             file a complaint with the Tax Department:
• a credit report less than 30 days old, and
                                                             –  Visit our website(search: rights)
• your last 12 months of statements from your bank or 
financial institution.                                       –  No Internet access? Call us at 518-457-3280 and we 
                                                                will mail you a statement of your rights.
Specificinstructions                                         Privacynotification
                                                             New York State Law requires all government agencies 
Section 1 – Taxpayer information                             that maintain a system of records to provide notification 
Enter the taxpayer’s full name and Social Security           of the legal authority for any request for personal 
number.                                                      information, the principal purpose(s) for which the 
Enter the spouse’s full name and Social Security number      information is to be collected, and where it will be 
(if applicable).                                             maintained. To view this information, visit our website, 
                                                             or, if you do not have Internet access, call and request 
Enter the taxpayer’s physical home address, telephone        Publication 54, Privacy Notification. See Need help? for 
number, and mailing address or PO box if different from      the Web address and telephone number.
home address.
If the taxpayer has a representative, enter the name, 
phone number, and address of the representative, and 
attach a completed power of attorney. We recommend 
POA-1, Power of Attorney, available at www.tax.ny.gov. 
If you use another power of attorney, it must include the 
same information as the POA-1.

Section2–Justificationfortheexemption
Provide all of the facts and reasons supporting the basis 
of your undue economic hardship claim. If you have 
attempted to obtain a restricted license, explain the status 
of that application. For more information about obtaining 
a restricted license, visit www.dmv.ny.gov and search 
restricted use. If needed, attach additional pages, and 
copies of appropriate documents, to fully and completely 
explain the details of your claim.

Section 3 – Signature
Sign and date. If you and your spouse are requesting a 
hardship exemption, both must sign.

Mailing your Form DTF-5.1
Along with your completed Form DTF-5.1, be sure to 
include a completed Form DTF-5. Include copies of your 
federal income tax returns for the last three years, copies 
of the last 12 months of statements from your bank or 
financial institution, and all other material required by 
Form DTF-5.
Mail all documents to:
       NYS TAX DEPARTMENT
       CED-DMV HARDSHIP
       W A HARRIMAN CAMPUS
       ALBANY NY 12227-5100
If not using U.S Mail, see Publication 55, Designated 
Private Delivery Services.