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Supreme Court ,ennsylvania
Courflof Commoilleas
Civil C 7ver Sheet
Cc)64-*Af'-': County
The infOrmation collected on this frill is used solely for court administration pwposes. This form does not
For Prothonotary Use Only:
Docket No:
;lob - O00q-3oJv
supplement or re lace tlwfi/ing and service 0- leadin s or other papers as required by law or rules oIcourt.
Commencement of Action:
0 Complaint . 0 Writ of Summons &Petition
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Lead PlaintiffNam:
...-ire) 1/-:( c (C
Lead Defendant's Name:
V4ni9 ti 04".
Dollar Amount Requested: 0 within arbitration limits
(check one) Doutside arbitration limits
Are money damages requested? M Yes No .
Is this a Class Action Suit? Yes g<
Is this an MDJ Appeal? Yes No
Name of Plaintiff/Appellant's Attorney:
Er Check here if you have no attorney (are a Self -Represented !Pro Se] Litigant)
Nature of the Case: Place an "X" to the left of the ONE case category that most accurately describes your
PRIMARY CASE. If you are making more than one type of claim, check the one that
you consider most important.
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o
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Updated 1/1/2011
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
. ov S cJcS
C'"3 r.,a
Vs. Driver's License/Auto Registration Appel r r'
111.
Commonwealth of Pennsylvania �. ¢' �_' ;
Department of Transportation < c _"
Bureau of Drivers Licensing z
(Type your name)
APPEAL OF DRIVER'S LICENSE/AUTO REGISTRATION SUSPENSION
AND NOW, this (enter today's date) 1 '10 , 20 15
a 2 tyles /4( .FS , by his/her attorney,
, comes the Appellant, (Type your name)
and states as follows:
1.. Appellant's PA operator's number or automobile registration number is:
%000'1.0
-1-21H 6oo90
2. PennDOT proposes, by Notice dated (insert "mailing" date here) , 20 , to suspend
Appellant's driving privileges ri automobile registration for a period of (Insert length of suspension)
pursuant to Section of the Vehicle Code, which
suspension is to be effective (Insert suspension effective date) , 20
****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)
The police lacked reasonable grounds to stop Appellant and / or request Appellant to submit to a chemical
test.
EAppellant did not knowingly or intelligently refuse a chemical test;
IJ 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:)
1
-OR -
The suspension of Appellant's automobile registration is contrary to law in that:
My failure to have insurance was for a period of Tess 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 PennDOT form MV -221 to document non -operation of the vehicle).
Other (specify reason:)
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WHEREFORE, Appellant respectfully requests this Honorable Court to sustain the appeal from the suspension
of operating privileges or automobile registration.
Respectfully submitted,
/14 name here)
C,rnes fir ct'
(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:
Type Name: te
Address:
City / State / Zip Code: Cl1 ,tel1S' 17115 1J2 17 ?5 7
Telephone Number: 7/7 `/ YC)
Email address: KC (p-veteS 2_7' @ 5/nal co/f
2
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF TRANSPORTATION
BUREAU OF MOTOR VEHICLES
PO BOX 68674
. • HARRISBURG, PA 17106-8674
www.dmv.state.pa.us
JAMES ANTHONY HICKS III
a SARAH LUCILLE HARRIS
64 BARD DR
SHIPPENSBURG, PA 17257
WID* 143349999072690 001
TITLE* 73743059
PROCESSING DATE 141130
TRANSACTION CODE 00060
OFFICIAL NOTICE MAIL DATE: 12/07/14
Dear Customer:
The Department recently requested that you provide us with proof of financial responsibility (insurance) for the
following vehicle:
MAKE: NISSAN YEAR: 2009 BODY TYPE: SEDAN
LICENSE PLATE#: JRI-I0040 TITLE#: 73743059 VIN##: 1N4CL21EX9C156123
This information was requested because GEICO CASULTY CO notified us that the insurance policy covering
the vehicle listed above was terminated on 10/10/14. Either no response was received or the information you
provided was not acceptable.
As a result, the registration for the vehicle listed above will be suspended for three months effective 01/11/15 at
12:01 A.M. as authorized by Section 1786(d) of the Vehicle Code.
THIS IS A FINAL ORDER OF SUSPENSION. You are required to return your current registration plate,
sticker and card to the Department immediately. Credit toward serving this suspension will not begin until the
Department receives your registration products. Additionally, you are required to pay a restoration fee in the
amount of $88.00 to the Department in accordance with Section 1960 of the Vehicle Code. Please make check
or money order payable to the PA Department of Transportation. Do not send cash. You can also pay by credit
card online at www.dmv.state.pa.us by selecting "Pay Your Financial Responsibility Restoration Fee". Within
30 days of your eligibility date for restoration, you will also be required to show proof of insurance for this vehicle.
We have enclosed a self-addressed envelope for your use when corresponding and a mailing label to assist with the
return of your registration plate, sticker and card. When the Department receives your registration products, we
will send you a letter within 3 weeks confirming that they were received. If, after 3 weeks of mailing your
registration .plate, sticker and card to the Department you do not receive a letter stating your registration products
were received, please contact us immediately.
You have the right to appeal this suspension to the Court of Common Pleas of the county of your residence within
thirty(30) days of the mail date of this letter. If you file an appeal in the County Court, the Court will give you
a time -stamped certified copy of the appeal. In order for the appeal to be valid, you must send this time stamped
certified copy of the appeal by certified mail to:
Pennsylvania Dept of Transportation
Office of Chief Counsel
1101 S Front Street -3rd Floor
Harrisburg, PA 17104-2516
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
e.5 f �e-Lirr
(Print your name)
Noc)-v rDdb I /466"k
Vs. Driver's License/Auto Registration Appeal
Commonwealth of Pennsylvania
Department of Transportation
Bureau of Driver Licensing
ORDER SCHEDULING HEARING ON APPEAL
AND NOW, this
% day ofteMileaoi 20/5, a hearing is scheduled
on the appeal of Petitioner for the 9M day of %!�%�ii(41 , 20/J at _9:Ja�'i M
in Courtroom #3 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, 3rd 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.
L £s 11 1 £,c
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Judge