Information Sheet For Limited Driving Privilege Petition Page 2
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1
2
3_______________________________
Case No. ___________________________________
Name of Petitioner
G
12 POINT SUSPENSION APPEAL PETITION
R.C. 4510.037(G) See Cost Schedule
______________________________________
Street Address
G
FINANCIAL RESPONSIBILITY SUSPENSION
______________________________________
PETITION FOR LIMITED DRIVING
City/State/ Zip
PRIVILEGES See Cost Schedule
G
(Class E - 3 month suspension)
Phone Number _________________________
R.C.4509.101(A)(2)(a)- 1st suspension
G
(Class C- 1 year suspension )
Social Security No._______________________
R.C.4509.101 (A)(2)(b)- 2nd suspension
License No. ____________________________
after 15 days
G
VS.
PETITION FOR EXTENSION OF TIME TO PAY
REINSTATEMENT FEES See Cost Schedule
REGISTRAR,
R.C. 4510.10(B)(2)
BUREAU OF MOTOR VEHICLES
Occupational/ Family Necessity Privileges
Driver’s License Division
Only
P.O. Box 16520
G
Columbus, Ohio 43266-0020
REINSTATEMENT FEE PAYMENT PLAN R.C.
BMV Case No. _________________________
4510.(B)(1) See Cost Schedule
Payments of not less than $50.00per month
No Driving Privileges Permitted
G I am requesting driving occupational driving privileges. I have attached proof of employment
showing the location of my employer(s), hours and days of employment.
G I am requesting driving privileges for educational, vocational, medical, or other reasons. I
have attached a schedule showing the specific purpose, location, dates, and times
that driving privileges are needed.
G
I have paid all reinstatement fees.
G
Or
I have not paid my reinstatement fees and request up to 90 days to pay the fees.
G
I have not paid my reinstatement fees and request a payment plan of $_____ per
month until the fee is paid in full. NO DRIVING PRIVILEGES REQUESTED
G
I did not cause any damage to any person/ property as a result of a motor vehicle
accident.
G
Or
I have paid for any damages I cause as a result of a motor vehicle accident.
This information is true to the best of my knowledge and I have attached proof of financial
responsibility.
Signed ____________________________________________________
Jan 2004
BMVPETITIONS
INFORMATION FOR DRIVING PRIVILEGES
Must accompany any BMV Petition
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