Los Santos Police Department

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PART I.

1. FIRST NAME: Derrick
2. SURNAME: Ziegler
3. CONTACT NUMBER: 2438430
4. ADDRESS (NUMBER & STREET): 7 Panorama Drive
5. CITY: Blaine County
6. STATE: San Andreas

VEHICLES TO BE REGISTERED FOR EXEMPTION:
Maximum of 2

• Vehicle: Vapid Sadler Retro Sport Crew Cab
  Plates: SCM413

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PART II.

MEDICAL DIAGNOSIS FOR EXEMPTION:
Skip if not applicable | (( Convert cb to cbc for a checkmark ))

Abinism
Chronic actinic dermatitis/actinic reticuloid
Dermatomyositis
Lupus erythematosus
Porphyria
Xeroderma (pigmentosa) pigmentosum
Severe drug photosensitivity provided that the course of treatment causing the photosensitivity is expected to be of prolonged duration
Photophobia associated with an ophthalmic or neurological disorder
If other condition or disorder causing severe photosensitivity in which a person is required to be shielded from sun rays for medical reasons, please fill the field in below:
Other: - Glaucoma

EVIDENCE OF MEDICAL DIAGNOSIS:
Medical diagnosis must provide the certified medical provider's name, examination date (must be within one month of from the date this form is submitted to the LSPD), and clinic name. Certified medical professional must have a San Andreas certification.

** ATTACHED DOCUMENTS IF APPLICABLE. **

ACCESS
ACCESS
ACCESS

EXEMPTION FOR CREDIBLE THREAT:
Credible threat is gauged by submitting a Crime Complaint Report to the Area Detectives Division. Once the Crime Complaint Coordinator has reviewed the presented evidence, they will inform the Traffic Division of approval or dismissal of the application for window tint exemption.

I confirm I have emailed the Crime Complaint Coordinator with a Crime Complaint regarding a credible threat.
Date Complaint Filed: DD/MMM/YYYY

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PART III.

I certify and affirm that all information presented in this form is true and correct, that any documents, including supporting documentation that I have presented to the Los Santos Police Department are true, accurate, and genuine. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal offense.

Signature of Vehicle Registrant:
Sign Name in Full

X Derrick Ziegler

Date:
10/08/2024

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To Mr Ziegler,

• Your application has been received and acknowledged by the Traffic Division. Your application will be reviewed within Seventy Two hours of receiving this notice.
  
  Please remain patient during this time and do not contact any Traffic Division members in attempts to speed up the process as this can result in your application being denied.

Respectfully,

Joey Petrovic
Police Officer III+1
Traffic Division
Los Santos Police Department

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To Mr Ziegler,

• Upon review of your tint exemption application, your application has been marked as PENDING for the following items:
  
  You have not attached a medical certificate from your doctor outlining the condition you have stated on your application. Please contact a doctor and attach a copy to your application in the next forty eight hours.
  
  At this time, you may elect to either withdraw your application or provide the additional information required within the next forty-eight (48) hours. Should you have any question, concern or require any information in regards to this decision, please do not hesitate to contact a Senior Traffic Officer, Traffic Division.

Respectfully,
Joey Petrovic
Police Officer III+1
Traffic Division
Los Santos Police Department

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To Mr Ziegler,

• Upon review of your tint exemption application, your application has been marked as DENIED due to the following items:
  
  Failed to submit relevant Documation in the given timeframe. May resubmit an application once they obtain the relevant medical documentation
  
  Should you have any question, concern or require any information in regards to this decision, please do not hesitate to contact a Senior Traffic Officer, Traffic Division.

Respectfully,

Joey Petrovic
Police Officer III+1
Traffic Division
Los Santos Police Department