Free mc210.p65 - Michigan

Approved, SCAO

Original - Court 1st copy - Defendant

STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE
Court address

CASE NO. AFFIDAVIT AND ORDER FOR RESTRICTED DRIVER'S LICENSE
Court telephone no.

The State of Michigan THE PEOPLE OF v

Defendant's name, address, and telephone no.

Driver's license no.

DOB

In the matter of AFFIDAVIT 1. I state that I am unable to take public transportation, and do not have family members or others able to provide transportation: a. to and from home to work only to and from home to work and for employer only Days Hours for employer only at:
Employer name and address or territory

to and from home to work only to and from home to work and for employer only for employer only at:
Employer name and address or territory

Hours

Days

b. to and from school
Hours Days School name

c. to and from

alcohol/drug education treatment.

probation.

community service.

d. to and from home or work and a place of regularly occurring medical treatment for a serious condition for me or a member of my household or immediate family.
Defendant signature

Subscribed and sworn to before me on My commission expires: Notary public, State of Michigan, County of

, Signature:
Notary public/Deputy court clerk

County, Michigan.

ORDER FOR RESTRICTED DRIVER'S LICENSE THE COURT FINDS: 2. The defendant's operator or chauffeur license was ordered suspended. 3. The defendant is unable able to take public transportation, or be provided transportation by family members or others, to and from the locations stated above. IT IS ORDERED: 4. The defendant's request is denied. 5. The Secretary of State shall issue the defendant a restricted driver's license if the defendant is otherwise eligible to be licensed.
Date MC 210 (5/07) Judge Bar no. MCL 333.7408a

AFFIDAVIT AND ORDER FOR RESTRICTED DRIVER'S LICENSE