COURT REPORT State of Alabama Unified Judicial System TO THE DEPARTMENT OF PUBLIC SAFETY, STATE OF ALABAMA, OF A CONVICTION OR ADJUDICATION Form UTTC-19 Rev. 8/09 REQUIRING SUSPENSION OR REVOCATION OF DRIVERS LICENSE WHERE NO UTTC HAS BEEN ISSUED This Report Contains Confidential Information on a Juvenile or Youthful Offender CASE NUMBER ALABAMA, COUNTY OF CO COURT ORI NUMBER CITY AL NAME: First Middle/Maiden NO OFFENSE DATE Month J Last YES Day Year DRIVER’S LICENSE NUMBER STATE Alias, If Known SEX CLASS RACE DATE OF BIRTH Street Address City State Zip SOCIAL SECURITY NUMBER - PLACE OF OFFENSE City and/or County COMMERCIAL MOTOR VEHICLE Yes No HAZARDOUS MATERIAL INVOLVED PASSENGER VEHICLE (requiring passenger endorsement) CONVICTED / ADJUDICATED OF CIRCUIT DISTRICT Yes Day Yes No CDL REQUIRED Yes No No DATE Month MUNICIPAL - OFFENSE CHARGED CODE SECTION / MUNICIPAL ORDINANCE VIOLATED Year JUVENILE COURT OF FINE COSTS TOTAL JAIL TERM Years Street Address Months Days TELEPHONE NUMBER ( City State INPATIENT TREATMENT ORDERED Zip Yes COURT ORDERED SUSPENSION __________________ MONTHS No LICENSE DESTROYED (DATE) _____/_______/________ DISTRIBUTION: Part 1 - DPS Reporting Copy )- ISSUANCE DATE ______/______/_______ ISSUANCE NUMBER _____ I HEREBY CERTIFY THE ABOVE TO BE A TRUE AND CORRECT ABSTRACT OF THE RECORD OF CONVICTION OF SAID PERSON IN THIS COURT. Part 2 - Court Record Copy License Attached Yes No ___________________________ Date of Report ____________________________________ Judge/Clerk Signature American LegalNet, Inc. www.FormsWorkFlow.com