AOC-492 Rev. 5-16 Page 1 of 2 Doc. Code: AAHD COM M O NW E A LT H O F K E lex et justitia Citation No. __________________ U C KY NT Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 189A.400 - 189A.460; 601 KAR 12.020 and 12.060 COMMONWEALTH OF KENTUCKY VS. Case No. ____________________ Court _______________________ County ______________________ PLAINTIFF DEFENDANT RT OF JUS TI Application for Hardship Driver's License ________________________________________________ Address: ________________________________________ ________________________________________________ Comes the Defendant and provides the following information in support of a request for a hardship license: 1. On _________________________________, 2_______, I [ ] plead guilty to OR [ ] was found guilty of violating KRS 189A.010. I was convicted as a(n): [] [] [] Offender 18 - 21 years old w/alcohol concentration of .02-.08 (license suspension period is 30 - 120 days); Under 18 Offender (license suspension period is longer of 30 - 120 days or until 18th birthday); First-time Offender (license suspension period is 30 - 120 days). 2. Due to this conviction, my Kentucky operators' license is suspended for ___________ [ ] days OR [ ] months. Said offense was committed __________________, 2______. Judgment was imposed __________________, 2_____. 3. The minimum license suspension period expired: __________________________, 2_______. 4. There was a judicial finding of refusal to take an alcohol concentration or substance test. [ ] Yes* [ ] No * KRS 189A.410(3) prohibits issuance of a hardship license to an individual who has refused a test. 5. Suspension of my driver's license hinders my ability to: (Check all that apply) [ ] Continue my employment. [ ] Obtain necessary medical care. [ ] Continue attending school or an educational institution. [ ] Attend court-ordered counseling or other programs. [ ] Attend driver improvement, alcohol, or substance abuse education programs. 6. At the hearing, I will provide to the Court proof of motor vehicle insurance and notarized documents, as stated on page 2 of this form, depending on whether the hardship license is sought for employment; educational; medical; alcohol; substance abuse education or treatment; court-ordered counseling; or other programs. WHEREFORE, Defendant prays this Application for Hardship Driver's License will be granted for the remainder of the suspension period. ____________________________________________ CLERK'S USE ONLY Hearing Date: _____________________, 2_____. Time: _________________ [ ] a.m. [ ] p.m. Defendant's Signature ___________________________________________ Defendant's Attorney (if any) Date: _____________________________, 2_______. American LegalNet, Inc. www.FormsWorkFlow.com C CO U E AOC-492 Rev. 5-16 Page 2 of 2 INSTRUCTIONS TO DEFENDANT FOR COMPLETING APPLICATION When filling in your NAME as the "DEFENDANT" on page one of this form, also include your ADDRESS. 1. You must provide the following type of NOTARIZED document(s) depending on the reason you are requesting a license. Form AOC-492.A "Affidavit for Hardship Driver's License" may be used for this purpose. A. If the license is sought for employment purposes: A written, sworn statement from your employer detailing your job, hours of employment, and the necessity for you to use a motor vehicle either in work at the direction of your employer during work hours, or in travel to and from work. If you are self-employed, provide the described information together with a sworn and notarized statement attesting to the truth of the above information. If the license is sought for education purposes: A written, sworn statement from the school or educational institution that you attend containing your class schedule, courses being taken, and necessity for you to use a motor vehicle in travel to and from school or other educational institution. A license for educational purposes shall not include participation in sports, social, extracurricular, fraternal or other noneducational activities. If the license is sought for medical purposes: A written, sworn statement from a physician or other medical professional licensed (but not certified) under Kentucky laws, attesting to your normal hours of treatment, and the necessity to use a motor vehicle to travel to and from the treatment. If the license is sought for alcohol or substance abuse education or treatment purposes: A written, sworn statement from the director of any alcohol or substance abuse education or treatment program as to the hours in which you are expected to participate in the program, the nature of the program, and the necessity for you to use a motor vehicle to travel to and from the program. If the license is sought for court-ordered counseling or other programs: A copy of any court order relating to treatment, participation in driver improvement programs, or other terms and conditions ordered by the court relating to you which require you to use a motor vehicle in traveling to and from the court-ordered program. The court order must include the necessity for use of a motor vehicle. B. C. D. E. 2. A sworn statement must be signed by a notary public. 3. NOTE TO DEFENDANT: You must pay a service fee to the Kentucky Transportation Cabinet for issuance of a hardship license. The Cabinet may refuse issuance of a hardship license should your driving history reveal a current withdrawal, denial, suspension, cancellation or revocation of driving privilege in any state/licensing jurisdiction. 601 KAR 12:020, Sec. 3. 4. IF YOU ARE COMPLETING THIS FORM ON A COMPUTER, SUBMIT THREE (3) SIGNED COPIES OF THE APPLICATION [plus the appropriate notarized Affidavit(s)] TO THE CIRCUIT CLERK. If you received this Application from the Circuit Clerk, submit only the completed three-page carbon pack [plus the appropriate notarized Affidavit(s)] to the Circuit Clerk. INSTRUCTIONS TO CLERK 1. 2. 3. Assign same case number as underlying charges. Stamp filed and file in same case jacket or file as underlying charges. Do NOT collect a filing fee. Set hearing date on next hearing day and write date and time on page 1 of this form. Copy Distribution: White - Court File Yellow - Defendant Pink - County Attorney American LegalNet, Inc. www.FormsWorkFlow.com