HomeMy WebLinkAbout11-7965IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
No.
(Type your name)
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Commonwealth of Pennsylvania
Department of Transportation
Bureau of Drivers Licensing
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Driver's License/Auto Registration Appeaier
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APPEAL OF DRIVER'S LICENSE/AUTO REGISTRATION SUSPENSION
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AND NOW, this (enter today's date) 6fkU?}e? ?' , 20 , comes the Appellant, (Type your name)
ayackQh rnLn?(l,f?n 0?? . by his/her attorney, and states as follows:
1. Appellant's PA operator's number or automobile registration number is:
2. PennDOT proposes, by Notice dated (insert "mailing" date here) 5kQVM b<? Z7,20 ? I to suspend
Appellant's driving privileges Elautomobile registration for a period of (Insert length of suspension)
Z-7 V C G(i S pursuant to Section
of the Vehicle Code, which
suspension is to be effective (Insert suspension effective date) V6Vefn6tC 20 1
****A copy of the Notice sent by PennDOT is attached to this Appeal****
3. The suspension of Appellant's operating privileges is contrary to law in that:
(Check those which apply)
Vr The police lacked reasonable grounds to stop Appellant and / or request Appellant to submit to a chemical
test.
1Z Appellant did not knowingly or intelligently refuse a chemical test;
The conviction on which Appellant's suspension is based was overturned by successful appeal, OR is currently
under appeal. (Attach a copy of the court docket this Appeal).
® Other (Specify reason:)
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-OR-
The suspension of Appellant's automobile registration is contrary to law in that:
? My failure to have insurance was for a period of less than 31 days AND I did not
drive nor permit anyone else to drive my vehicle during the time it was without
insurance. (Attach proof of insurance to this Appeal and either a notarized
statement of PermDOT form MV-221 to document non-operation of the vehicle).
Other (specify reason:)
WHEREFORE, Appellant respectfully requests this Honorable Court to sustain the appeal from the suspension
of operating privileges or automobile registration.
Respectfully submitted,
/
(Sign name here)
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(Type name here)
VERIFICATION
The undersigned hereby states that the statements made in the attached Appeal of Suspension or
Registration are true and correct to the best of my knowledge, information and belief. The undersigned understands
that the statements in the attached Appeal are made subject to the penalties of 18 Pa. C.S. Sec. 4904 relating to
unsworn falsification to authorities.
Signature: 1 v"
Type Name: C I?YWII 61
Address:
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City /State /Zip Code: A-12,57
Telephone Number:
Email address: M IA-\
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
of\'a kvm)( No. -7q( , 5- c-v,
(Type your name)
Vs. Driver's License/Auto Registration Appeal
Commonwealth of Pennsylvania
Department of Transportation
Bureau of Driver Licensing
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on CCl OW 0< , 20\\ , I caused to be
mailed by regular mail, postage prepaid, a copy of the Appeal, Order Scheduling Hearing, and
all attachments, to:
Office of Chief Counsel
Vehicle and Traffic Law Division
Riverfront Office Center, 3`d Floor
1101 South Front Street
Harrisburg, PA 17104-2516
Date: 0JrjbCr- ? j 20 ?
Signature:
Type your Name: ml ! lCi `1 Y 1Gth ?{?lf u??
Address: 10 L fa(- \ 2
City / State / Zip Code: h 2A
?,
11 Telephone: isn - Zq?--LA 221
** This form must be completely filled out and filed in the Prothonotary's office
promptly after mailing the documents to PennDOT **
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
(Print your name)
Vs.
Commonwealth of Pennsylvania
Department of Transportation
Bureau of Driver Licensing
No. 6 Z
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Driver's License/Auto Registration Arlulwl1 rv : ,:..
ORDER SCHEDULING HEARING ON APPEAL
02? day of 20_[L__, a hearing is scheduled
AND NOW, this
on the appeal of Petitioner for theme day of 20 at ?: 22 4M
U in Courtroom # a--of the Cumberland County Courthouse, One Courthouse Square, 4th Floor, Carlisle,
PA 17013, at which time testimony will be taken and argument heard.
A copy of this Order has been served on Appellant. It shall be Appellant's responsibility to serve
a copy of this Appeal, all attachments, and this Order on the attorney for the Commonwealth, at the
following address:
Office of Chief Counsel
Vehicle and Traffic Law Division
Riverfront Office Center, 3`d Floor
1101 South Front Street
Harrisburg, PA 17104-2516
It shall further be Appellant's responsibility to file a Certificate of Service with the Prothonotary
stating that service was made on the Commonwealth of Pennsylvania.
By the Court,
Judge
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