Fill and Sign the I Certify that on the Day of 20 at a Form

I certify that on the ___________ day of _______________ 20_____, at ________ a.m./p.m., I issued Complaint-Summons # ______________________ to the above-named defendant for failing to possess or exhibit an insurance identification card in violation of N.J.S.A. 39:3-29 while operating a: Year: ___________ Make: _____________________ Model:____________________________ License Plate #: ________________ VIN #: ____________________________________________________ Registered to ____________________________________ at: ____________________________________________. (Name) (Address) . Immediately thereafter, I provided a Written Notice of Potential Impoundment to the defendant of his/her responsibility under N.J.S.A. 39:3-29.1a to provide proof of insurance to the _________________________________ _________________ within 24 hours, a copy of which is attached. (Name and Address of Law Enforcement Agency) More than 24 hours have elapsed since I issued th is Complaint-Summons to the defendant and the defendant has failed to provide an insurance identification card or other satisfactory proof of insurance to the above law enforcement agency. Therefore, I request that the Court issue a Warr ant of Impoundment for this vehicle, pursuant to N.J.S.A. 39:3- 29.1a. I certify that the foregoing statement s made by me are true. I am aware that if any of the foregoing statements made by me are wilfully false, I am subject to punishment. Submitted by: ______________________________________ Badge #: ____________ (Print name of law enforcement officer) _____________ ______________________________________ (Date) (S ignature of law enforcement officer) State of New Jersey v. _________________ Defendant WARRANT OF IMPOUNDMENT N.J.S.A. 39:3-29.1a Municipal Court of ____________ THIS MATTER having been brought to the attention of the Court by the above Certification signed by a duly authorized law enforcement officer, and the Court having considered the Ce rtification and supporting document(s) submitted, IT IS THEREFORE ORDERED ON THIS _________ day of _________________ , 20_____ that this Warrant of Impoundment be issued as a result of the defendant’s failur e to provide an insurance identification card or other satisfactory proof of insurance within 24 hours of the issuance of the above referenced Complaint-Summons for failing to possess or exhibit an insurance identification card in violation of N.J.S.A. 39:3-29. Any law enforcement officer to whom this Warrant of Impoundment is presented is hereby commanded to impound the above-described vehicle and re move it to a storage space or garage, designated for that purpose. _______________________ _______________________________ (Date) , J.M.C. 6/04 State of New Jersey v. _______________________ Defendant CERTIFICATION