STATE OF NORTH CAROLINA County IN THE MATTER OF: Name And Address Of Petitioner File No. In The General Court Of Justice District Court Division LIMITED DRIVING PRIVILEGE Driving While License Revoked Or Committing Moving Offense While Driving During Period Of Revocation Drivers License No. State Race Sex Height Date Of Birth Weight Hair Color Eye Color NOTE: THIS IS A CIVIL DISTRICT COURT ACTION. Use this form to issue a limited driving privilege under G.S. 20-20.1 when the petitioner's drivers license is revoked under G.S. 20-28 (driving while license revoked) or G.S. 20-28.1 (committing moving offense while driving during period of revocation). FINDINGS Upon the petition of the person named above for a limited driving privilege, the Court finds that 1. The petitioner's drivers license has been revoked by the North Carolina Division of Motor Vehicles under G.S. 20-28 (driving while license revoked); G.S. 20-28.1 (committing moving offense while driving during period of revocation); 2. The petitioner has has not satisfied the eligibility requirements under G.S. 20-20.1 as listed on form AOC-CV-353; and 3. The petitioner has furnished to the Court a properly executed form DL-123, or equivalent proof of financial responsibility, and the Court is satisfied that the petitioner is financially responsible. a properly executed form DL-123A and the Court is satisfied that the petitioner is not required to provide proof of financial responsibility. ORDER 1. It is ORDERED that the petitioner be allowed a limited driving privilege to become effective on the date indicated below and to be used in accordance with the restrictions imposed on the reverse of this form. This privilege shall expire one year from the effective date indicated below, or upon the end of the revocation period under G.S. 20-28 or G.S. 20-28.1, whichever occurs sooner. This limited driving privilege is conditioned upon the maintenance of financial responsibility as required by G.S. 20-20.1(i) during the period of the privilege. 2. It is ORDERED that the petitioner NOT be allowed a limited driving privilege. Effective Date Of Limited Driving Privilege Date Of Order Signature Of Judge Name Of Judge (Type Or Print) NOTE TO DEFENDANT: This limited driving privilege is no longer valid after the end of one year from the effective date indicated above, or after the end of the revocation period under G.S. 20-28 or G.S. 20-28.1, whichever occurs sooner. AOC-CV-354, New 12/07 � 2007 Administrative Office of the Courts Original-File Certified Copy-Defendant (Over) Copy-DMV American LegalNet, Inc. www.FormsWorkFlow.com LIMITED DRIVING PRIVILEGE The driver shall not consume alcohol while driving or drive at any time while the driver has remaining in his or her body any previously consumed alcohol. The driver shall not drive at any time while the driver has remaining in his or her body any previously consumed controlled substance, unless the controlled substance was lawfully obtained and taken in therapeutically appropriate amounts. The driver must maintain financial responsibility as required by G.S. 20-20.1(i) during the period of this limited driving privilege. This limited driving privilege DOES NOT include the privilege of operating a commercial motor vehicle as defined in G.S. 20-4.01(3d). Driving when essential for the emergency medical care of the driver, or for an immediate family member of the driver who resides in the same household with the driver, is authorized at any time. Standard working hours are 6:00 AM to 8:00 PM, Monday through Friday. Driving, other than for emergency medical care, is permitted only as follows: (check only applicable boxes) 1. Driving is permitted for work-related purposes during standard working hours as follows: 2. Driving is permitted for maintenance of household during standard working hours as follows: 3. Driving is permitted for work-related purposes during nonstandard working hours as follows: The driver is self-employed and the required documentation for work-related driving is attached. 4. Driving is restricted to any non-commercial vehicle registered in the name of the driver. the following non-commercial vehicle(s): 5. Additional restrictions: Other: (specify) Corrective Lenses 45 M.P.H. Daylight Only Name And Address Of Employer Or Driver's Place Of Work NOTICE/ACKNOWLEDGMENT OF RECEIPT I have received a copy of this limited driving privilege, which contains the restrictions on my privilege to drive. I understand that if I drive with the odor of alcohol on my breath, I may be subject to arrest and to the loss of this limited driving privilege. I also understand that this is my limited license to drive; that I must keep it in my possession during the period of revocation; that if my drivers license is revoked for any other reason, this limited driving privilege is invalid; and that a violation of any restriction imposed in connection with this limited driving privilege constitutes the offense of driving while license revoked under G.S. 20-28(a). Date Signature Of Petitioner CERTIFICATION I certify that this is a true and complete copy of the original on file in this case. Date Signature Deputy CSC Clerk Of Superior Court Assistant CSC NOTE TO CLERK: The clerk must send a copy of this limited driving privilege, and a copy of any subsequent order modifying or revoking this limited driving privilege, to the North Carolina Division of Motor Vehicles. AOC-CV-354, Side Two, New 12/07 � 2007 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com