Fill and Sign the Rhymes with Right and Folks Wonder Why Some of Us See Form

State of Alabama Unified Judicial System Form UTTC-19 Rev. 9/07 COURT REPORT TO THE DEPARTMENT OF PUBLIC SAFETY, STATE OF ALABAMA, OF A CONVICTION OR ADJUDICATION REQUIRING SUSPENSION OR REVOCATION OF DRIVERS LICENSE WHERE NO UTTC HAS BEEN ISSUED This Report Contains Confidential Information on a Juvenile or Youthful Offender YES NO OFFENSE DATE CO CITY CASE NUMBER ALABAMA, COUNTY OF COURT ORI NUMBER AL J Month Day Year DRIVER’S LICENSE NUMBER NAME: First Middle/Maiden Last STATE CLASS Alias, If Known SEX RACE DATE OF BIRTH Street Address SOCIAL SECURITY NUMBER City State Zip - - PLACE OF OFFENSE City and/or County OFFENSE CHARGED COMMERCIAL MOTOR VEHICLE Yes No HAZARDOUS MATERIA L INVOLVED Yes No PASSENGER VEHICLE (requiring passenger endorsement) Yes No CDL REQUIRED Yes No DATE CONVICTED / ADJUDICATED OF Month Day Year CODE SECTION / MUNICIPAL ORDINANCE VIOLATED FINE COSTS TOTAL JAIL TERM CIRCUIT DISTRICT MUNICIPAL JUVENILE COURT OF Years Months Days Street Address TELEPHONE NUMBER ( ) - City State Zip COURT ORDERED SUSPENSION __________________ DAYS DISTRIBUTION: Part 1 - DPS Reporting Copy Part 2 - Court Record Copy License Attached Yes No I HEREBY CERTIFY THE ABOVE TO BE A TRUE AND CORRECT ABSTRACT OF THE RECORD OF CONVICTION OF SAID PERSON IN THIS COURT. ___________________________ ____________________________________ Date of Report Judge/Clerk Signature