Form Aa-33a - Administrative Appeal Form

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New York State Department of Motor Vehicles
DMV USE ONLY
ADMINISTRATIVE APPEAL FORM (AA-33A)
VEHICLE AND TRAFFIC LAW ARTICLES 3-A and 12-A
(THIS FORM IS NOT TO BE USED TO APPEAL TRAFFIC VIOLATION BUREAU TICKETS)
WHAT IS REQUIRED TO FILE AN APPEAL
You must send this
(2 pages) and a
to the DMV Appeals Board. Read this entire form carefully.
COMPLETED, SIGNED APPEAL FORM
$10 APPEAL FEE
Type or print all information clearly. You must state your reason for the appeal on page 2 of this form. You must pay a non-refundable
$10 appeal fee for
. DO NOT SEND CASH. Appeal fees must be paid by check or money order, payable to the “Commissioner of Motor
each CASE NUMBER you appeal
Vehicles.” Print your case number(s) on your check or money order. A $35 penalty is charged for dishonored checks.
WHERE TO SEND AN APPEAL
DEADLINE TO FILE AN APPEAL
Mail the appeal form and
You must send this
to the DMV Appeals Board
APPEAL FORM and the APPEAL FEE(S)
WITHIN SIXTY (60)
appeal fee(s) to:
DAYS OF THE DATE OF THE DEPARTMENT’S ORDER OF SUSPENSION/REVOCATION, DECISION LETTER,
DMV APPEALS BOARD
. If you file by mail, the USPS postmark will be used to determine if your appeal is timely. If the
OR NOTICE
P.O. BOX 2935
postmark is illegible, the date your appeal is received by the Board will determine timeliness. You should keep
ALBANY, NY 12220-0935
copies of your completed appeal form, appeal fee, and proof of mailing.
WHAT IS THE SUBJECT OF YOUR APPEAL (Check the appropriate box.)
CHEMICAL TEST REFUSAL– DMV HEARING HELD
DENIAL OF APPLICATION FOR DRIVER LICENSE, CERTIFICATE OR PRIVILEGE – NO DMV HEARING HELD
FACILITY LICENSE OR CERTIFICATE, including INSPECTION STATION, INSPECTOR, DEALER, REPAIR SHOP – DMV HEARING HELD
FATAL ACCIDENT, PERSISTENT VIOLATOR, FALSE STATEMENT– DMV HEARING HELD
ALL OTHERS – including OTHER DETERMINATIONS MADE WITHOUT A DMV HEARING
HEARING TRANSCRIPTS
If a hearing was held, the Appeals Board may review hearing testimony only if you order and pay for a transcript in a proper and timely manner. The Appeals
Board will acknowledge receipt of your appeal form and fee with a letter that will direct you to send a transcript deposit to the designated Transcription company
within 30 days of the date of the letter. The Appeals Board does not accept transcript payments. If you do not receive an acknowledgment letter, contact the Appeals
Board at (518) 474-1052 or at the address above. The Appeals Board will not review hearing testimony unless all transcript payments are timely and complete.
IF A HEARING WAS HELD, check the appropriate box below:
I WANT THE HEARING TESTIMONY REVIEWED BY THE BOARD. I UNDERSTAND THAT I AM REQUIRED TO PAY A TRANSCRIPT DEPOSIT TO THE
TRANSCRIPTION COMPANY WITHIN 30 DAYS OF THE DATE OF THE LETTER ACKNOWLEDGING RECEIPT OF THIS APPEAL.
I DO NOT WANT A TRANSCRIPT OF THE HEARING TO BE PRODUCED. I UNDERSTAND THAT THE BOARD WILL NOT REVIEW HEARING TESTIMONY.
REQUESTING A STAY
I REQUEST THAT THE FINE, SUSPENSION OR REVOCATION BE STAYED (STOPPED) PENDING THE OUTCOME OF THE APPEAL.
Stays pending appeals are granted in the discretion of the Board (except for most Article 12-A appeals). The Appeals Board will not grant a stay unless the
appeal fee is paid and valid reasons for the appeal and for needing the stay are provided on page 2 of this form. You will be notified whether your request
for a stay has been granted or denied.
REQUIRED APPEAL INFORMATION
All correspondence for this appeal will be sent to the address(es) supplied on this appeal form. You must notify the Appeals Board in writing immediately of
any change of address that occurs after this appeal is filed.
Last Name
First Name
M.I.
Type of Appeal (Chemical Test Refusal, License Denial, Inspection, Dealer, Repair Shop, etc.)
Date of Birth:
NYS Driver License
Sex
MM
DD
YYYY
Client ID Number
Male
Female
Corporate Name or DBA
Facility/Certificate Number
Appeal Mailing Address (Street)
Case Number(s)
City
State
Zip Code
Date of Each Hearing
ATTORNEY FOR THIS APPEAL (if any)
Date of Decision/Order
Attorney Mailing Address (Street)
Hearing Location(s)
City
State
Zip Code
Administrative Law Judge
DATE:
STAY:
DMV
$10 APPEAL FEE(S) RECEIVED
NO FEE RECEIVED
MM
DD
YYYY
USE
CHECK
MONEY ORDER
AMOUNT: $
ONLY
YOU MUST COMPLETE PAGE 2 OF THIS FORM.
PAGE 1 OF 2
AA-33A (5/13)

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