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T-215 (Revised 4-2012) - Continued
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Section VI.
Alternate Driver’s Statement of Need (Choose & complete one of the following):
□
The co-owner of the vehicle, ____________________________________________, is completely
(Co-owner’s Full Legal Name)
dependent upon the motor vehicle referenced in Section II for the necessities of life and would be
subject to undue hardship without such special license plate for the following reason(s):
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OR
□
A member of the suspended driver’s/habitual violator’s family, __________________________________, is
(Family Member’s Full Legal Name)
completely dependent upon the motor vehicle referenced in Section II for the necessities of life and
would be subject to undue hardship without such special license plate for the following reason(s):
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Section VII.
Notarized Signatures
Suspended Driver’s/Habitual Violator’s Signature:
Date:
Alternate Driver’s Signature:
Date:
Sworn to and subscribed before me this __________ of ____________________________, 2_______.
(Day)
(Month)
(Year)
______________________________________________
______________________________________
(Notary Public’s Signature & Notary Seal or Stamp)
(Date Notary Commission Expires)
Section VIII.
Department’s Decision
□
Denied*
DOR SEAL
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(Authorized Signature)
(Date)
*If your application is denied and you believe that the decision was made in error, you may submit a request for an
administrative hearing before the Office of the State Administrative Hearings by submitting a written request to the Department.
Appellate procedures and rights in administrative hearings are governed by the Administrative Procedures Act, O.C.G.A.
§50-13-
1, et seq.
Section IX.
Department’s Decision
□
Approved – The County Tag Office must issue a temporary operating permit (TOP) for the ‘AI’ plate category.
DOR SEAL
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(Authorized Signature)
(Date)
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