File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division County IN THE MATTER OF Name And Address DRIVERS LICENSE PICK-UP ORDER Race Sex Height Hair Color Eye Color Weight DOB G.S. 20-16.5 Drivers License No. State TO ANY LAW ENFORCEMENT OFFICER: You are ORDERED to pick up the drivers license issued to the person named above in accordance with G.S. 20-29 and deliver it to the undersigned within three (3) days of the surrender. Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court RETURN OF SERVICE I certify that this Order was received and served as follows: Date Received Date Served 1. by personally serving the person named above and picking up the attached drivers license. 2. the person named above demonstrated that he/she is not currently licensed. 3. the person named above was not served for the following reason: Date Of Return Signature Of Law Enforcement Officer No. Department Or Agency NOTICE TO PERSON SERVED Your license to drive is revoked. Unless the revocation is indefinite, your license will remain revoked for at least a day period beginning on the day you surrender your license or show that you are not currently licensed to drive. If the revocation is indefinite, your license will be revoked for that period or until a final judgment, including appeals, has been entered for the current offense and for all pending offenses for which your drivers license had been or is revoked under G.S. 20-16.5. At the end of the revocation period you are still prohibited from driving until you have paid a $100 fee to the Clerk of Superior Court. This $100 fee may be paid at any time, even prior to the end of the revocation period, between the hours of 8:30 a.m. and 5:00 p.m., Monday through Friday. Payment in person must be paid in cash, by certified check or money order. Payment by mail must be made by certified check or money order, made payable to the Clerk of Superior Court. This fee is in addition to any fee you have paid or are to pay in connection with any other pending offense for which your drivers license has been or is revoked under G.S. 20-16.5. If prior to the effective date of this Order you were not licensed by the North Carolina Division of Motor Vehicles or did not have a valid license from another state, an additional $50 restoration fee must be paid to the Division of Motor Vehicles before you can drive again in North Carolina. This fee must be paid even though you are a resident of another state. You have a right to a hearing to contest the validity of this Revocation before a magistrate or judge. To do so a written request must be made within ten (10) days of the effective date of the revocation. A hearing request form is available from the office of the Clerk of Superior Court or magistrate. Your license will remain revoked and you are not authorized to drive pending the hearing. If you do request a hearing but fail to appear, you forfeit the right to a hearing. IT IS UNLAWFUL FOR YOU TO DRIVE A MOTOR VEHICLE IN THE STATE OF NORTH CAROLINA UNTIL YOU ARE AUTHORIZED TO DO SO. AOC-CVR-4, Rev. 8/07 © 2007 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkflow.com