Clear Form
HBAC Form 1
REQUEST FOR AN ORDER/AUTHORIZATION TO REMOVE
BREATH ALCOHOL IGNITION INTERLOCK DEVICE
This form should only be used by individuals with one conviction of
Operating a Motor Vehicle with an Alcohol Content of .17 or more.
Full Name ________________________________________________________________________________________
(Please print exactly as it appears on your driver’s license or personal identification card issued by the State of Michigan.)
Street Address _____________________________________________________________________________________
City _________________State _______ZIP Code ______________ Birthdate
Michigan Driver’s License Number _____________________________________ Telephone ________________
(8 a.m. - 5 p.m.)
Attorney’s Name ____________________________________________________ Bar Number P- ________________
(If retained for this matter)
Attorney’s Address _________________________________________________________________________________
Attorney’s Telephone __________________________________ Attorney’s Fax____________________________
My Period of License Restrictions is Completed
(including any additional periods of suspension/restriction).
I request an Order/Authorization to Remove Breath Alcohol Ignition Interlock Device and have
___
enclosed an Ignition Interlock Report from the interlock vendor. I understand that the department will
review the Ignition Interlock Report and if it reveals a blood alcohol level of 0.025 grams or higher per
210 liters of breath, I may receive an additional period of suspension. I also understand the
department will mail an order after the review has been completed.
Signature ____________________________________________________
Date _____________________________
PLEASE FORWARD THIS FORM AND IGNITION INTERLOCK REPORT TO:
Michigan Department of State
Administrative Hearings Section
P.O. Box 30773 ● Lansing, MI 48909-7696
1-888-SOS-MICH
(1-888-767-6424)
Revised 9/26/ 2013