Fill and Sign the In the Court of Appeals of the State of Mississippi No 95 Ca 00909 Coa Form

IN THE CIRCUIT COURT OF COUNTY, MISSISSIPPI , PLAINTIFFVS. NO. , COMMISSIONER OF PUBLIC SAFETY OF THE STATE OFMISSISSIPPI, DEFENDANT PETITION TO REVIEW SUSPENSION FOR REFUSAL TO TAKE_BREATH_TEST COMES NOW the Defendant, , by and through his/her attorney of record, and files this his/her Petition to Review Suspension for Refusal to Take Breath Test pursuant to 63-11-25 Miss. Code Ann. (1988 Supp.) and in support thereof would show unto the Court the following, to-wit: 1. That the Plaintiff, , is an adult resident citizen of County, Mississippi, whose mailing address is . 2. That pursuant to Rule 4(D)(5) of the Miss. Rules of Civil Procedure, the Defendant, 5, as Commissioner of Public Safety may be served with process of this Court by duly serving said process on the Attorney General of the State of Mississippi. 3. That this Honorable Court has subject matter jurisdiction of the cause of action herein pursuant to Section 63-11-25 Miss. Code Ann. (1988 Supp.) and other applicable statutes. 4. That on , 20 , the Defendant was charged with operating a motor vehicle while under the influence of intoxicating liquor in violation of 63-11-30(1)(a) Miss. Code Ann. 1972. 5. That on the above mentioned date the Defendant was further charged with refusing to submit to a breath test in violation of 63-11-21 Miss. Code Ann. 1972. 6. That on , , the Defendant received notice from the Department of Public Safety advising the defendant that his/her driver's license would be suspended for a period of ninety (90) days for refusing to submit to a breath test. The date of said notice reflects that it was issued on . The Plaintiff did not receive said notice until . This is evidenced by a copy of the envelope in which the notice was mailed and is attached hereto and marked Exhibit " ". The return of the United States Post Office reflects the Plaintiff received said notice on . 7. That the Defendant did not refuse to take the breath test but was denied the opportunity to submit to a breath test. 8. That pursuant to 63-11-25 Miss. Code Ann (1988 Supp.) the Defendant may and hereby does petition the Court to review the decision of the Department of Public Safety to suspend the driving privileges of the Defendant.WHEREFORE, PREMISES CONSIDERED the Defendant, , respectfully requests that this Honorable Court review the Decision of the Department of Public Safety to suspend the Defendant's driving privileges for failure to submit to a breath test and upon completion of said review, issue its Order reinstating the driving privileges of the Defendant. Respectfully submitted,_______________________________________ Attorney for Of Counsel: Telephone: MSB # Attorney for