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Application for Child Safety Seat

  1. Application for Child Safety Seat

    Fill in form completely.

  2. I am requesting a child safety seat for:

  3. Child's Race

  4. Child's Ethnicity

  5. Relationship to this child:

  6. I am a Virginia resident.

  7. I or my child is a US citizen or a documented alien.

  8. I or my child receives FAMIS, WIC, Medicaid, or TANF

  9. Electronic Signature*

    By checking the box below, I am providing my electronic signature.

  10. Issue Information

  11. Leave This Blank:

  12. This field is not part of the form submission.