PETITION FOR FORFEITURE CIVIL DOCKET NO. OF MOTOR VEHICLE OR VESSEL G.L. c. 90, § 24W Trial Court of Massachusetts District Court Department District Court DESCRIPTION OF MOTOR VEHICLE(s) OR VESSEL(s) (include year, make & model) COMMONWEALTH vs. __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ LOCATION OF MOTOR VEHICLE(s) OR VESSEL(s) (identify as particularly as possible) VIN(s) OF MOTOR VEHICLE(s) OR VESSEL(s) NAME & ADDRESS OF RESPONDENT (CRIMINAL DEFENDANT) RESPONDENT’S DOB DOCKET NO. OF CRIMINAL CASE NAME(s) & ADDRESS(es) OF OTHER OWNERS OR OTHERS WITH APPARENT INTEREST IN MV(s) OR VESSEL(s) POLICE DEPT(s) SUBSTANTIALLY INVOLVED IN FORFEITURE Was any such motor vehicle(s) or vessel(s) jointly owned before the date of respondent’s second or subsequent qualifying offense by a parent, spouse, child, grandparent, brother, sister, or parent of the spouse living in respondent’s household? 9 YES 9 NO 1. As detailed below and in the attached affidavit(s), there is probable cause to believe that the motor vehicle(s) and/or vessel(s) described above are at the location named above and are owned by the respondent named above. 2. (Check A or B) : 9 9 3. (A) 4 prior assignments/convictions: The respondent has at least four times been assigned to an alcohol or controlled substance education, treatment or rehabilitation program or been convicted of a violation of G.L. c. 90, § 24(1)(a) or § 24G(a), or of operating a motor vehicle with a percentage by weight of blood alcohol of eight one-hundredths or greater or while under the influence of intoxicating liquor under § 24G(b), or of § 24L, or of G.L. c. 90B, § 8(a), § 8A or § 8B, or of G.L. c. 265, § 13½, or of a like offense in another jurisdiction. The undersigned hereby petitions this court in the name of the Commonwealth to order, after hearing, that the motor vehicle(s) and/or vessel(s) described above be forfeited to the Commonwealth pursuant to G.L. c. 90, § 24W. (B) 3 prior assignments/convictions and another pending charge: The respondent has at least three times been so assigned or convicted for such qualifying offenses, and a criminal complaint charging the respondent with a fourth such qualifying offense is presently pending before this court. The undersigned hereby petitions this court in the name of the Commonwealth, upon such an assignment or conviction for such fourth qualifying offense, to order, after hearing, that the motor vehicle(s) and/or vessel(s) described above be forfeited to the Commonwealth pursuant to G.L. c. 90, § 24W. 9 Additional request for preliminary order to seize and secure. As detailed in the attached affidavit(s), there are also reasonable grounds to believe that it is necessary to issue a preliminary order to seize and secure such motor vehicle(s) and/or vessel(s) and to provide for their custody during the pendency of this petition. (Check if applicable.) DATE SIGNED PETITIONER’S SIGNATURE X PETITIONER’S TITLE 9 ASST DISTRICT ATTORNEY PETITIONER’S AGENCY 9 ASST ATTORNEY GENERAL (5/07) American LegalNet, Inc. www.FormsWorkFlow.com