Fill and Sign the I Have Received from the Department of Social Services Notice of Intent to Suspend or to Refuse to Renew My Drivers License for Form

PETITION FOR RESTRICTED DRIVER’S LICENSE – Case No. ................................................................................................ . FAILURE TO PAY CHILD SUPPORT Commonwealth of Virginia VA. CODE § § 46.2 -320.1 , 18.2-271.1 HEARING DATE: ................................................................................. ......................................................................................................................................................... Juvenile and Domestic Relations District Court .............................................................................................................................. ........................................................................................................................ PETITIONER DRIVER’S LICENSE NUMBER STATE .............................................................................................................................. ........................................................................................................................ ADDRESS DATE OF BIRTH .............................................................................................................................. CITY/STATE ZIP To the Judge of the above -named court: I have received from the Department of Social Services notice of intent to suspend or to refuse to renew my driver’s license for failure to pay child support or failure to comply with process relating to a paternity or child support proc eedings. Accordingly, I respectfully request that the court issue a restricted driver’s license, for good cause shown, for the following purposes: [ ] travel to or from my place of e mployment. [ ] travel to and from VASAP. [ ] travel during my hours of employment, because the operation of a motor vehicle is neces sary to my employment described below. ............................................................................................................................................................................................................................................................. EMPLOYER NAME AND WORK LOCATION ............................................................................................................................................................................................................................................................. HOURS FOR TRAVEL TO AND FROM WORK HOURS OF EMPLOYMENT [ ] travel to and from school. (I understand that I must provide proper written verification to the c ourt that I am enrolled in a continuing program of education.) ............................................................................................................................................................................................................................................................. SCHOOL NAME AND LOCATION ............................................................................................................................................................................................................................................................. REQUESTED DATES AND TIMES FOR TRAVEL TO AND FROM SCHOOL [ ] medically necessary travel for [ ] me [ ] elderly parent [ ] person residing in m y household. (I understand that I must provide written verification from a licensed health professional of the need for such travel for an elderly pare nt or household member.) ............................................................................................................................................................................................................................................................. NAME AND LOCATION PROVIDER OF MEDICAL SERVICES [ ] travel necessary to transport a minor child under my care [ ] to and from school [ ] to and from day care and/or [ ] to and from facilities housing medical service pro vider. ............................................................................................................................................................................................................................................................. NAME AND LOCATION OF SCHOOL/DAY CARE/MEDICAL SERVICES PROVIDER ............................................................................................................................................................................................................................................................. [ ] travel to and from court -ordered visitation with my child or children. ............................................................................................................................................................................................................................................................. NAME(S) AND LOCATION OF CHILD OR CHILDREN [ ] travel to and from appointments with my probation of ficer. ............................................................................................................................................................................................................................................................. NAME AND LOCATION OF PROBATION ENTITY [ ] travel to and from programs required by court or as conditions of probation. ............................................................................................................................................................................................................................................................. PROGRAM NAME AND LOCATION [ ] travel to and from a place of religious place of worship. ............................................................................................................................................................................................................................................................. NAME AND LOCATION OF PLACE OF RELIGIOUS WORSHIP ............................................................................................................................................................................................................................................................. REQUESTED DAY (ONE DAY PER WEEK) AND TIME FOR TRAVEL TO AND FROM PLACE OF RELIGIOUS WORS HIP [ ] travel to and from appointments approved by the Division of Child Support Enforcement of the Depa rtment of Social Services as a requirem ent of participation in an administrative or court-ordered intensive case monitoring program for child support which I will have proof of the appointment, including written proof of the date and time of the appointment. [ ] travel to and from jail to ser ve a jail sentence that is to be served on weekends or on nonconsecutive days. [ ] travel to and from a job interview for which I will have with me written proof from my potenti al employer of the date, time and location of the job interview. I understan d that the court may decide not to issue a restricted driver’s license. I under stand that a restricted driver’s license will not permit me to operate a commercial motor vehicle. I understand that a restricted driver’s l icense will not authorize visitation of my child or children if visitation is otherwise prohibited. ................................................................................................ ______________________________________________________________ DATE PETITIONER’S SIGNATURE FORM DC -281 MASTER 07/17