Fill and Sign the Fillable Online File No State of North Carolina Form

NOTE TO DEFENDANT: (check only one) The applicant 's North Car olina drive rs license is r evo ked because o f a convi ction in anot her ju risdict ion on a char ge subst antially similar to impair ed driving under G.S . 20- 138. 1; T he applicant has has not satisf ied t he eligibilit y requir ement s under G.S . 20- 179. 3 a t this t ime . It is O RDE RED that the applicant N O T be allowed a limi ted driving privilege at this t ime . It is O RDE RED that the applicant be allowed a limi ted driving privilege t o be effe ctive on t he date indica ted below, to be used in acco rdance wit h t he r estri ctions imposed on the r eve rse o f this f orm, and t o e xpir e one year fr om t he date on which the Divi sion of Mo to r V ehicles r evo ked t he applicant 's drive rs license pur suant to G.S. 20- 23. T his limited d riving privilege is condit ioned upon t he maint enance o f financial r esponsibilit y as r equir ed by G.S . 20- 179. 3(l) dur ing t he per iod of this privilege. 1 . S ignatur e Of C hief Distr ict C ourt Judge Nam e Of C hief Distr ict C ourt Judge ( Type Or Print) D ate Effecti ve Date ORDE R 2. T he r eco rd s of the Division of Mo to r V ehicles and the Cler k of S uper ior Court in this count y have been searched, and t her e a re no other re vocations in effe ct at this t ime ; and 3. 1. 2. 4. T he applicant would be eligible f or a limi ted driving privilege if the convi ction had occu rred in North Car olina and, if applicable, the period of nonoper ation has expir ed; a . b . The applicant has exe cu ted f orm DL- 123A and is not requir ed to f urnish p roof of financial r esponsibilit y. FINDI NG S STA TE OF NOR TH CAROLI NA File N o. Or igi nal -F ile Cer tified C opy-D efendant C opy-D M V ( Ov er) AO C-CV- 352, Rev . 10/ 15 © 2015 A dm ini strat iv e Offi ce of the Courts The Court has been f urnished a p roper ly exe cu ted f orm DL- 123 and is sa tisf ied t hat the applicant is f inancially r e sponsible. Upon applica tion of the applicant fo r a limi ted driving privilege, the Court finds t hat: Hai r C olor NOTE: Date Of Offense Race Sex Eye C olor Hei ght Date Of Bir th D river s Li cense N o. And S tate Date Of C onviction THI S IS A C IV IL ACTION . U se t his f orm w hen t he applicant 's license is r evoked because of a convi ction in anot her jur isdi ction subst antially si m ilar to im pai red drivi ng unde r G.S . 20- 138. 1. Weight IN T H E MA TTER OF: Count y LIMITED DRI VING PR IVILEG E I MPA IR ED DRI VING (OU T-OF -STA TE O R FED ERAL C O NVIC TION S) G.S . 20- 179. 3 In T he G eneral Cour t Of Ju stice Distri ct Court Division Nam e A nd A ddress Of Applicant Thi s pr ivilege is no longe r valid after the r evocation per iod f or the offense of whi ch you wer e convi cted has ended , or if your driver s license r emains r evoked sol ely because the Divi sion of Mot or Vehi cles has not obtained a certi ficat e of your complet ion of a subst ance abuse treatment progr am or an al cohol and drug educa tion traffi c school . 5. Deputy C SC C ler k Of S uperior C our t 1. 2. 3. 4. 6. A ddi tional r e st rict ion s: CER TIF IC ATIO N Driving is permi tte d fo r w ork-r ela ted, religious worship, o r edu cational p urp ose s during st anda rd w orking hou rs as f ollow s: I h ave r e ce ive d a co py of th is Limi te d D riving P rivilege whi ch co ntain s th e r e st rict ion s on my driving p rivilege . I unde rst and t h at if I drive w it h th e odo r of a lcohol o n my bre ath , I ma y be su bje ct to a rr est and lo ss of th is limi te d d riving p rivilege ; I unde rst and th at th is is my limi te d lice nse to d rive ; th at I mu st keep it in my posse ssion d uring th e p eriod o f r e vo cation ; th at i f my drive rs lice nse is re vo ked fo r any oth er re aso n, th is Limi te d D riving P rivilege is in valid ; th at a viola tion o f a ny r e st rict ion imp ose d in conne ction w it h th is Limi te d D riving P rivilege co nst it u te s th e o ffe nse o f d riving while lice nse r e vo ked unde r G.S . 2 0-2 8; th at if co mmuni ty se rvi ce h as been o rd ere d, my willfu l failu re to p ay th e p re scr ibed fe e o r co mple te t h e co mmuni ty se rvi ce w it hin th e time limi t imp ose d shall r e su lt in r e vo cation o f th is Limi te d D riving P rivilege ; and th at my will fu l failu re ma y also r e su lt in o th e r act ion a uth orize d b y law fo r viola tion o f a condi tion o f p roba tion . NO TIC E/ACKN OWLE DG ME NT O F R EC EIP T Signatur e Of Applicant I ce rtif y th at th is is a t ru e and co mple te co py of th e o riginal o n file in th is ca se. Signatur e Assi stant C SC The d rive r shall n ot d rin k alcohol while d riving o r drive while a ny alcohol r e main s in h is/ her bod y. T he d rive r shall n ot d rive while h aving a co ntr olled su bst ance in h is/ her bod y unle ss such co ntr olled su bst ance w as law full y obtained and ta ke n in t h erapeu ticall y app ro ve d a moun ts. T he limi te d d riving p rivilege D O ES N O T in clude t h e p rivilege o f ope ra ting a co mme rcial mo to r vehi cle a s defined in G .S . 2 0-4 .0 1(3 d). D riving when e sse ntial fo r eme rgen cy medi cal ca re is auth ori ze d a t a ny time . S tanda rd w orking hou rs are f ro m 6 A M to 8 P M, Monda y - Frida y. D riving , o th er than fo r eme rgen cy medi cal ca re , is permi tte d onl y as follow s: (check o nly app licable b oxe s) REST RIC TIO NS Driving is permi tte d fo r main tenan ce o f hou sehold d uring st anda rd w orking hou rs as follow s: Driving is permi tte d fo r w ork-r ela ted, religious worship, o r edu cational p urp ose s during non standa rd w orking hou rs as f ollow s: T he d rive r is se lf e mplo yed and th e r equi re d d ocu me nta tion fo r w ork-r ela te d d riving is atta ched . Driving is permi tte d fo r co mmuni ty se rvi ce a ssign ment, Alcohol and D ru g E duca tion T ra ffic School , and su bst ance abu se a sse ssme nt o r t re atme nt a s follow s: Dayligh t O nly O th er: ( speci fy) 4 5 M. P.H . Only C orr ect ive Len ses Date Date Nam e A nd A ddress Of AD ET S chool, C ommunity S ervice C oordinator , Or M ental Heal th T reatm ent F acility To W hich D river Assi gned Nam e A nd A ddress Of E mployer Or Driver' s Place Of W ork AO C-CV -352, S ide Tw o, R ev . 10/ 15 © 2015 A dm ini strat iv e Off ice of the Cour ts Driv ing is re stricte d to : a ny n on-comme rcial vehicle re giste red in th e n ame of th e d riv er. th e fo llowin g n on-comme rcial vehicle(s): a . b . 5. Th e a bove v ehicle sh all b e e quippe d with a fu nctio nin g ig nitio n in terlo ck syste m of a typ e a ppro ve d b y th e Co mmissio ner of Mo tor Ve hicles a nd th e d efenda nt sh all p erso nally a ctivate th e ig nitio n inte rlock syste m befo re o peratin g th e v ehicle. Th e d riv er ma y drive to and fro m a ny ig nitio n inte rlock se rvice facility fo r installatio n a nd se rvice p urp oses.