CIV111 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 2State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: Other Civil Petitioner (first, middle, last) Respondent Commissioner of Public Safetyvs.Petition for Hearing on Reinstatement of Driver's License (Minn. Stat. 247 171.19)Petitioner petitions this Court for reinstatement of his/her driving privileges pursuant to Minn. Stat. 247171.19 and states as follows:1. My name is and I currently live at Street Apt. # City State Zip Code County2. On or about (date), I received notice from the Department of Public Safety, Driver and Vehicle Services Division, that stated my driver's license will be or was (check the box that applies): refused suspended revoked cancelled disqualifiedeffective (date), for a period of days years.3. The notice states that my license was taken because: and that the incident occurred in (name of city) .4. My license was not revoked or disqualified under Minn. Stat. 247 169A.52 for failing or refusing a chemical test to determine intoxication, and was not suspended for nonpayment of support under Minn. Stat. 247 171.186. 5. For the license problem described at #2 and #3: American LegalNet, Inc. www.FormsWorkFlow.com CIV111 State ENG Rev 7/15www.mncourts.gov/formsPage 2 of 2 This is the first time I have filed a court Petition for reinstatement of my driver's license I previously filed a Petition and the court denied my request to get my driver's licenseORreinstated. The hearing date was and today is at least 1 year sincethe hearing date. (If it is less than one year, you cannot file now.)6. My date of birth is 7. My driver license number is 8. I believe my license should be reinstated because: 9. I am filing this petition within 180 days of the effective date of the order of revocation, suspension, cancellation, disqualification or refusal notice. I am filing this petition before the expiration date of the revocation, suspension,cancellation, disqualification or refusal.Wherefore, petitioner seeks judgment of this Court as follows: 1. Reinstatement of petitioner222s driving privileges pursuant to Minn. Stat. 247171.19. 2. For such other and further relief as the Court deems just and proper. Dated: Signature Name: Address: City/State/Zip: Telephone: E-mail address: County and State where signed American LegalNet, Inc. www.FormsWorkFlow.com