State of Minnesota County Judicial District: Court File Number: Case Type: Civil District Court Petition for Review of Administrative Impoundment Order (License Plates) (Minn. Stat. §169A.60, subd. 10) Petition for Approval of Issuance of Special Plates After Judicial Impoundment Order (Minn. Stat. §168.041, subd. 6) Petition for Approval of Transfer of Vehicle After Judicial Impoundment Order (Minn. Stat. §168.041, subd. 7) ___________________________________________ vs. Petitioner Commissioner of Public Safety Respondent STATE OF MINNESOTA COUNTY OF ) ) SS ) , petitioner states that my current address is My date of birth is My driver's license number is: My license plate number is: The date of the violation is: The violation is: The name of the violator is: _____________________________________ FOR602 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com The law enforcement agency that issued the plate impoundment order is: ____________________________________________________________ An impoundment order was issued on by Judge County District Court or by the Commissioner of Public Safety. in I request that the Court allow the impounded plates in the above entitled matter to be returned to Petitioner according to Minn. Stat. §169A.60, subd. 10. I request that the Court allow the Commissioner of Public Safety to issue special plates according to Minn. Stat. §168.041, subd. 6. I request that the Court allow transfer of title to the vehicle subject to the judicial impoundment order according to Minn. Stat. §168.041, subd. 7. I request this for the following reasons: 1. 2. 3. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Dated: Signature Name: Address: City/State/Zip: Telephone: ( E-mail address: ) Page 2 of 3 FOR602 State ENG Rev 7/15 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com State of Minnesota County Judicial District: Court File Number: Case Type: Civil District Court ORDER vs. ___________________________________________ Petitioner The hearing was held/the matter was considered on by Judge in District Court. After considering the file and records, It Is Ordered: Commissioner of Public Safety Respondent County The impoundment order is: Stayed for the balance of impoundment period (impounded plates are returned) Rescinded (impounded plates are returned) Sustained (impounded plates continue to be impounded) The Commissioner of Public Safety shall issue special plates to the following: (petitioner's name, address, plate #) The Court does/does not certify consent for transfer of title for the registered owner's motor vehicle. Dated: Judge of District Court ___ Copy for Prosecutor Distribution ___ Copy for Plaintiff ___ Copy for Commissioner FOR602 State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com