State of Alabama UJS FORM UTC-5 Rev.6 / 85 CASE NUMBER SUPPLEMENTAL DISPOSITION (TRAFFIC APPEAL) CC _____ ____________ YR. NUMBER NAME OF DEFENDANT BIRTH DATE MO DAY STATE DRIVER’S LICENSE NUMBER YR COURT ORI NUMBER UTC SERIES & NUMBER AL J TYPE TRIAL JURY TR NON-JURY LOWER COURT CASE NUMBER ______ _________________ YR NUMBER ATTORNEY FOR DEFENDANT WAIVED COUNSEL FINDING OF THE COURT: GUILTY AS CHARGED NOT GUILTY GUILTY OF LESSER CHARGE OF : ______________________________________________________________________ NOL PRESSED CASE DISMISSED MUNICIPAL APPEAL DISMISSED REFERENCE: SECTION ______________________________________________________________________, CODE OF ALABAMA, 1975. MUNICIPAL ORDINANCE NUMBER/SECTION _____________________________________________________________________________________ COURT ORDERS: FINE$ _________________________ + COURT COSTS $ _________________________ + TOTAL $ __________________ JAILED ___________ DAY(S) IN _________________________________________________________________________ COURT REFERRAL PROGRAM DUI DDC LOCATION _______________________________________________________________ OR ID # ______________________ LICENSE SUSPENDED: ________________ DAY(S) ___________________ MONTH(S) __________________ YEAR(S) OTHER SENTENCE PROVISIONS: I HEREBY CERTIFY THAT THIS IS A TRUE COPY OF THE RECORD OF THIS COURT. MO DAY YR ________________________________________ SIGNATURE-JUDGE/CLERK DATE LICENSE ATTACHED YES ORIGINAL: TO DPS WITH UTC NO DPS RECEIVED LICENSE YES NO PART 2: TO LOWER COURT American LegalNet, Inc. www.USCourtForms.com