STATE OF ILLINOIS CIRCUIT COURT OF LAKE COUNTY Revocation of Certificate of Relief From Disabilities Case Number: Holder of Certificate: Address: Street City State Zip Social Security #: Offense of Conviction: Date Certificate was Issued: Date of Birth: Date of Sentence: Pursuant to the provisions of 730 ILCS 5/5-5.5-35, this certificate of relief from disability is hereby revoked, and the holder is directed to surrender the certificate to this court. A person who knowingly uses or attempts to use a revoked certificate in order to obtain or to exercise any right or privilege that he or she would not be entitled to obtain or to exercise without a valid certificate is guilty of a Class A misdemeanor. This revocation shall be filed with the Illinois Department of Professional Regulation and the Illinois State Police. Judge's Signature: Date: Copies To: Department of Professional Regulation Licensing & Testing Division 320 W. Washington Street Springfield, IL 62786-0002 Illinois State Police Bureau of Identification 260 N. Chicago Street Joliet, IL 60432 American LegalNet, Inc. www.USCourtForms.com