File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division County IN THE MATTER OF Name And Address Of Petitioner REQUEST FOR HEARING TO CONTEST LICENSE REVOCATION Home Telephone No. Work Telephone No. G.S. 20-16.5 TO THE APPROPRIATE JUDICIAL OFFICIAL: I request a hearing to contest the validity of the revocation of my drivers license which was ordered revoked on the date set forth below. I challenge the validity of the revocation on the following specific ground(s): (NOTE: List the finding(s) for probable cause, as set forth on the Revocation Order, which you believe to be wrong.) I specifically request that the hearing be conducted by a District Court Judge. I understand that the hearing will be limited to the grounds I specify in this request and that the revocation of my drivers license remains in effect pending the hearing. I further understand that this hearing must be held and completed within three (3) working days following the date of this request, or within five (5) working days if I have requested a District Court Judge to conduct the hearing. I also understand that my failure to appear at the hearing will result in the forfeiture of my right to a hearing. I understand that the decision of the Magistrate or District Court Judge at the hearing is final, and that there is no right of appeal from the decision. Date License Revoked Date Signature Of Petitioner ORDER SETTING HEARING The defendant having requested a hearing, the undersigned hereby sets a time, date and location of hearing as shown below. Date Of Hearing Time Of Hearing Date AM Location Of Hearing PM Signature Deputy CSC Assistant CSC Clerk Of Superior Court Magistrate FILING INSTRUCTIONS This request must be filed by the Petitioner within ten (10) days of the effective date of the revocation order with one of the following: 1. Judicial official at the initial appearance; or 2. The Clerk of Superior Court; or 3. A Magistrate designated by the Clerk of Superior Court to receive such requests. AOC-CVR-5, Rev. 8/07 © 2007 Administrative Office of the Courts Original-File Copy-Petitioner (Over) American LegalNet, Inc. www.FormsWorkflow.com File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division County IN THE MATTER OF Name And Address Of Petitioner FINDINGS AND ORDER IN CONTESTED LICENSE REVOCATION G.S. 20-16.5 The Court finds that the petitioner filed a timely Request For Hearing To Contest License Revocation form setting forth the specific grounds upon which the validity of the revocation is challenged. The Court, having considered the evidence and arguments presented at the hearing, finds by the greater weight of the evidence the following: 1. The hearing a. was held and completed within the required time limits. b. was not held and completed within the required time limits. 2. As to each condition alleged by the law enforcement officer and chemical analyst in this matter, a. all were met. b. at least one was not met. c. other than the current offense, there are no additional pending offenses for which the person's drivers license had been or is revoked under G.S. 20-16.5. Based upon the foregoing findings of fact, the Court CONCLUDES and ORDERS that the revocation of the petitioner's license be: a. sustained. b. rescinded. c. the indefinite suspension is rescinded and a separate order shall be entered by an appropriate judicial official revoking the petitioner's drivers license for an appropriate period. Date Name Of Judicial Official (Print Or Type) Signature Of Judicial Official Judge AOC-CVR-5, Side Two, Rev. 8/07 © 2007 Administrative Office of the Courts Original-File Magistrate Copy-Petitioner American LegalNet, Inc. www.FormsWorkflow.com