Original - Court 1st copy - Defendant Approved, SCAO STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE CASE NO. AFFIDAVIT AND ORDER FOR RESTRICTED DRIVER'S LICENSE Court address Court telephone no. Defendant's name, address, and telephone no. The State of Michigan THE PEOPLE OF v Driver's license no. DOB In the matter of AFFIDAVIT 1. I state that I am unable to take public transportation, and do not have family members or others able to provide transportation: a. to and from home to work only to and from home to work and for employer only Days Hours for employer only at: Employer name and address or territory to and from home to work only to and from home to work and for employer only for employer only Hours Days at: Employer name and address or territory b. to and from school Hours c. to and from Days alcohol/drug education treatment. School name probation. community service. d. to and from home or work and a place of regularly occurring medical treatment for a serious condition for me or a member of my household or immediate family. Defendant signature Subscribed and sworn to before me on My commission expires: , Signature: County, Michigan. Notary public/Deputy court clerk Notary public, State of Michigan, County of ORDER FOR RESTRICTED DRIVER'S LICENSE THE COURT FINDS: 2. The defendant's operator or chauffeur license was ordered suspended. 3. The defendant is unable able to take public transportation, or be provided transportation by family members or others, to and from the locations stated above. IT IS ORDERED: 4. The defendant's request is denied. 5. The Secretary of State shall issue the defendant a restricted driver's license if the defendant is otherwise eligible to be licensed. Date MC 210 (5/07) Judge AFFIDAVIT AND ORDER FOR RESTRICTED DRIVER'S LICENSE Bar no. MCL 333.7408a American LegalNet, Inc. www.FormsWorkflow.com