Free cc295.pmd - Michigan

Approved, SCAO

Original - Court 1st copy - Secretary of State 2nd copy - Petitioner 3rd copy - Attorney General/Prosecutor

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Court address

CASE NO. APPEAL OF SUSPENSION, REVOCATION, OR DENIAL OF DRIVER'S LICENSE
Court telephone no.

Petitioner's name, address, and telephone no.

Respondent

v
Date of birth

Driver's license no.

SECRETARY OF STATE OF THE STATE OF MICHIGAN Driver Assessment and Appeal Division PO Box 30196 Lansing, Michigan 48909-7696
Respondent's attorney, bar no., address, and telephone no.

Petitioner's attorney, bar no., address, and telephone no.

1. I request a review of the action of the Secretary of State dated Date restriction, or denial of my driving privileges. 2. I am appealing the record pursuant to MCL 257.323(4).

that resulted in suspension,

findings of a license appeal hearing pursuant to MCL 257.323(2).

3. The action should be set aside because it was in violation of the constitution of the United States, the state constitution of 1963, or a statute as described below. in excess of the Secretary of State's statutory authority or jurisdiction as described below. made upon unlawful procedure resulting in material prejudice to the petitioner as described below. not supported by competent, material, and substantial evidence on the whole record as described below. arbitrary, capricious, or clearly an abuse or unwarranted exercise of discretion as described below. affected by other substantial and material error of law as described below.
(Provide details for each of the boxes that are checked. If necessary attach separate sheets.)

4. I request that the driving record/transcript be prepared by the Secretary of State pursuant to MCL 257.323(1) and filed with the court, and that upon review of the record, the court set aside the Secretary of State's action for the grounds stated above.
Date Signature of petitioner

ORDER FOR HEARING IT IS ORDERED: A hearing on the petition shall be held on at
Date Day and date

at

Time

the court address above.

Location Judge

CERTIFICATE OF MAILING I certify that on this date I served a copy of this appeal and order for hearing on the parties or their attorneys by first-class mail addressed to their last-known addresses as defined in MCR 2.107(C)(3).
Date CC 295 (3/08) Signature of petitioner

APPEAL OF SUSPENSION, REVOCATION, OR DENIAL OF DRIVER'S LICENSE

MCL 257.323, MCL 257.323a-c