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State of New Jersey v. _______________________
Defendant

CERTIFICATION

I certify that on the ___________ day of _______________ 20_____, at ________ a.m./p.m., I issued Complaint-Summons # ______________________ to the above-named defendant for failing to possess or exhibit an insurance identification card in violation of N.J.S.A. 39:3-29 while operating a: Year: ___________ License Plate #: Make: _____________________ ________________
(Name)

Model:

____________________________

VIN #: ____________________________________________________
(Address)

Registered to ____________________________________at: ____________________________________________. . Immediately thereafter, I provided a Written Notice of Potential Impoundment to the defendant of his/her responsibility under N.J.S.A. 39:3-29.1a to provide proof of insurance to the _________________________________ _________________ within 24 hours, a copy of which is attached. (Name and Address of Law Enforcement Agency) More than 24 hours have elapsed since I issued this Complaint-Summons to the defendant and the defendant has failed to provide an insurance identification card or other satisfactory proof of insurance to the above law enforcement agency. Therefore, I request that the Court issue a Warrant of Impoundment for this vehicle, pursuant to N.J.S.A. 39:329.1a. I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are wilfully false, I am subject to punishment. Submitted by: _____________ (Date) ______________________________________ (Print name of law enforcement officer) ______________________________________ (Signature of law enforcement officer) Badge #: ____________

State of New Jersey v. _________________
Defendant

WARRANT OF IMPOUNDMENT
N.J.S.A. 39:3-29.1a

Municipal Court of ____________

THIS MATTER having been brought to the attention of the Court by the above Certification signed by a duly authorized law enforcement officer, and the Court having considered the Certification and supporting document(s) submitted, IT IS THEREFORE ORDERED ON THIS _________ day of _________________ , 20_____ that this Warrant of Impoundment be issued as a result of the defendant's failure to provide an insurance identification card or other satisfactory proof of insurance within 24 hours of the issuance of the above referenced Complaint-Summons for failing to possess or exhibit an insurance identification card in violation of N.J.S.A. 39:3-29. Any law enforcement officer to whom this Warrant of Impoundment is presented is hereby commanded to impound the above-described vehicle and remove it to a storage space or garage, designated for that purpose.

_______________________ (Date)
6/04

_______________________________ , J.M.C.