File No. STATE OF NORTH CAROLINA In The General Court Of Justice Superior Court Division District County STATE VERSUS Name And Address Of Defendant INTERLOCK LIMITED DRIVING PRIVILEGE IMPAIRED DRIVING (N.C. CONVICTIONS ONLY) Race Sex Height Weight Hair Color Eye Color Date Of Birth G.S. 20-179.3 Drivers License No. State Date Of Conviction Date Of Offense NOTE: Use AOC-CV-352 when the defendant's license was revoked for a conviction in another state or in a federal court. NOTE: If the defendant's license is revoked for a conviction of G.S. 20-138.1 and the defendant had an alcohol concentration of 0.15 or more, the following restrictions apply to the limited driving privilege: 1) the limited driving privilege may not become effective until at least 45 days after the final conviction under G.S. 20-138.1; 2) the defendant may operate only a designated motor vehicle; 3) the designated motor vehicle must be equipped with a functioning ignition interlock system of a type approved by the Commissioner of Motor Vehicles that is set to prohibit driving with an alcohol concentration of greater than 0.00; 4) the defendant must personally activate the ignition interlock system before driving the motor vehicle; 5) the defendant may drive only to and from the defendant's place of employment, the place the defendant is enrolled in school, any court-ordered treatment or substance abuse education, and any ignition interlock service facility. (Applies to offenses committed on or after December 1, 2007.) FINDINGS Upon application of the defendant for a limited driving privilege, the Court finds that: 1. The defendant has been convicted of impaired driving under G.S. 20-138.1; G.S. 20-138.2; G.S. 20-138.3; 2. At the time of the offense, the applicant held either a valid drivers license or a license that had been expired for less than one (1) year; 3. At the time of the offense, the defendant had not within the preceding seven (7) years been convicted of an offense involving impaired driving; 4. Punishment level three, four, or five has been imposed upon the defendant for the offense of impaired driving, or the defendant has been convicted under G.S. 20-138.3; 5. Subsequent to the offense, the defendant has not been convicted of, or had an unresolved charge lodged against the defendant for, an offense involving impaired driving; 6. The records of the Division of Motor Vehicles and the Clerk of Superior Court in this county have been searched, and there are no other revocations in effect at this time; 7. The defendant has obtained and filed with the court a substance abuse assessment; 8. If convicted under G.S. 20-138.3, the defendant was 18, 19 or 20 years old on the date of the offense and has not previously been convicted of a violation of G.S. 20-138.3; 9. The defendant was convicted under G.S. 20-138.1 and had an alcohol concentration of 0.16 0.15 (use for offenses committed on or after December 1, 2007) or more. 10. a. The Court has been furnished a properly executed form DL-123 and is satisfied that the defendant is financially b. responsible. ORDER It is ORDERED that the defendant be allowed a limited driving privilege to be effective on the date indicated below to be used in accordance with the restrictions imposed on the reverse of this form, and to expire one year from the date on which the Division of Motor Vehicles revokes the defendant's drivers license pursuant to G.S. 20-17(a)(2). This limited driving privilege is conditioned upon the maintenance of any financial responsibility required by G.S. 20-179.3(l) during the period of this privilege. Effective Date Date NOTE TO DEFENDANT: This privilege is no longer valid after the revocation period for the offense of which you were convicted has ended, or if your drivers license remains revoked solely because the Division of Motor Vehicles has not obtained a certificate of your completion of a substance abuse treatment program or an alcohol and drug education traffic school. Signature Of Judge AOC-CR-340, Rev. 12/07 © 2007 Administrative Office of the Courts Original - File Name Of Judge (Type Or Print) Certified Copy - Applicant (Over) Copy - DMV American LegalNet, Inc. www.FormsWorkflow.com RESTRICTIONS The driver shall not drink alcohol while driving or drive while any alcohol remains in his/her body. The driver shall not drive while having a controlled substance in his/her body unless such controlled substance was lawfully obtained and taken in therapeutically approved amounts. This limited driving privilege DOES NOT include the privilege of operating a commercial motor vehicle as defined in G.S. 20-4.01(3d). Standard working hours are from 6 AM to 8 PM, Monday - Friday. Driving is permitted only as follows: (check only applicable boxes.) 1. (Do not check these items if 0.15 or greater alcohol concentration and offense committed on or after December 1, 2007.) Driving is permitted: a. when essential for emergency medical care at any time. b. for maintenance of household during standard working hours as follows: c. for community service assignment as follows: 2. Driving is permitted for work-related or educational purposes during standard working hours as follows: 3. Driving is permitted for work-related or education 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 permitted for Alcohol and Drug Education Traffic School and substance abuse assessment or treatment as follows: 5. Driving is restricted to: , a. The following non-commercial vehicle(s): which shall be equipped with a functioning interlock system of a type approved by the Commissioner of Motor Vehicles and the defendant shall personally activate the ignition interlock system before operating the vehicle and at any time during the driving as required by the procedures for ignition interlock systems established by the Commissioner of Motor Vehicles. The driver may drive to and from any ignition interlock service facility for installation and service purposes. b. The following non-commercial vehicle(s): , which is owned by the defendant's employer and is operated by the defendant solely for work-related purposes, and the vehicle owner has filed a written statement with the court authorizing such work-related driving by the defendant. 6. Additional restrictions: Other: Corrective Lenses 45 M.P.H. Only Daylight Only Name And Address Of ADET School, Community Service Coordinator, Or Mental Health Name And Address Of Employer Or Driver's Place Of Work Treatment Facility To Which Driver Assigned NOTICE/ACKNOWLEDGMENT OF RECEIPT I have received a copy of this limited driving privilege which contains the restrictions on my driving privilege. I understand that if I drive with the odor of alcohol on my breath, I may be subject to arrest and loss of this limited driving privilege; I 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; 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); that if community service has been ordered, my willful failure to pay the prescribed fee or complete the community service within the time limit imposed shall result in revocation of this limited driving privilege; and that my willful failure may also result in other action authorized by law for violation of a condition of probation. Date Signature Of Defendant CERTIFICATION I certify that this is a true and complete copy of the original on file in this case. Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court AOC-CR-340, Side Two, Rev. 12/07 © 2007 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkflow.com