Fill and Sign the State of North Carolina Petition for Limited Driving Privilege Form

STATE OF NORTH CAROLINA File No. Hair Color Eye Color Date Of Birth Drivers License No. And State Date And Jurisdiction Of Conviction(s) NOTE: THIS IS A CIVIL ACTION. Civil costs re quirements must be satisfied when this P etiti on is filed. Use this form for petitions for limited driving privilege when the conviction that causes the revocation does not occur in the county in which the limited driving privilege is being sought. If the judge determines that a limited driving privilege is appropriate, AOC-CV-351 or AOC-CV-352 should be used. Offense(s) Sp eeding: Out-Of-County/Out-Of-State Or Federal Convictions OR DWI: Out-Of-State Or Federal Convictions IN THE MATT ER OF: PETIT ION FOR LI MIT ED DRIVIN G PRIV ILEGE G.S. 20-16(e1), 20-16.1 (b)(3), 20-179.3(d) Sex Height Race Weight Name, Address, And Telephone No. Of Petitioner 5. My lic ense was rev oked by the North Caroli na Divisi on of Motor V ehicles, effective on I am eligible for a limit ed driv ing privilege under I m eet all t he eligibility requirem ents un der t he statute c hecked . G.S. 20-16 (e1 ). I ha ve attac hed I ha ve attached a c opy of my drivi ng record. T he record has be en certifi ed by t he North Carol ina Divisi on of Motor V ehicles. I, t he un dersi gned petitioner, r equest t he Cou rt to iss ue a limit ed drivi ng privil ege for t he revocat ion list ed be low: 1. for a period of for the con victi ons(s) list ed above. 2. G.S. 20-16 .1(b)(3). G.S. 20-179.3(d). 4. a properly executed form DL-123 or equiv alent proof tha t I am financially responsible. a properly execut ed form DL-123A stati ng tha t I am not requir ed to furnish proof of financial responsibility. 3. I ha ve attached t he requir ed do cum entati on of my need to engage in employ ment relat ed drivi ng. Signature Of Petitioner Date , Date AM PM Assistant CSC Clerk Of Superior Court Deputy CSC Noti ce To The District Attorney: NOTICE OF HE ARING Name Of Judge (Type Or Print) Date Time Signature The petitioner named above will ap ply to t he Di strict Court J udge named bel ow for issuance o f a limit ed driving priv ilege at t he da te, time and place s hown below: Place Ot he r: I certify pursuant to G.S . 20 -179.3(d) t hat on thi s da te, I filed a c opy of t his Petition with the Di stric t A ttor ne y's o ffice CERTIFI CATIO N in pe rson . by depositing same in the U.S . mail in an en velo pe bearing proper postage. . Deputy CSC Cl erk Of Superior Court Assistant CSC WAIVER Signature Date Date NO TE: I, the un ders igned distric t att or ne y, waive the statutor y req uirem ent of t he Cler k to file a c opy of t his Petition with the Di stric t A ttor ne y's o ffice and furt her waive the right to appear a t a hearing on thi s Petition for limit ed driving priv ilege. Signature Of District Attorney Name Of District Attorney (Type Or Print) The Clerk of Superior Court upon the filing of this Petition with a notice of hearing, should i mmediately file a copy with the District Attorney's office and sign the certification. If the District Attorney waives the right to having this Petition filed with District Attorney's office, the Clerk has no further responsibility. Co unty In T he Gener al Cour t Of Justice Di strict Court Divis ion AOC-CV-350, Rev. 6/12 © 2012 Administrative Office of the Courts