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Click ‘Get Form’ to open the TC 94-178 document in the editor.
Begin with SECTION 1: DRIVER INFORMATION. Fill in your full name, mailing address, city, state, and zip code. Ensure all details are accurate for proper identification.
Continue by providing your residential street address, city, driver license number, plate number, VIN, year, and make/model of your vehicle. Double-check these entries for correctness.
Move to SECTION 2: INSTALLER STATEMENT INFORMATION. Enter the name and phone number of the installer who removed the ignition interlock device along with their street address, city, state, and zip code.
In SECTION 3: DEVICE PROVIDER INFORMATION, input the company name and address of the device provider. Include their phone number and device model number as well.
Finally, complete SECTION 4: SIGNATURE & DATE by printing your name (the individual removing the device), entering the removal date, and signing where indicated.

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