STATE OF NORTH CAROLINA County Name And Address Of Defendant File No. STATE VERSUS In The General Court Of Justice Superior Court Division District LIMITED DRIVING PRIVILEGE FELONY CONVICTION Race Hair Color Sex Eye Color Height Date Of Birth Weight G.S. 15A-1331.1; 20-15.1, 20-179.3 Drivers License No. And State Date Of Conviction Offense For Which Defendant Was Convicted FINDINGS The defendant has been convicted of a felony, and the defendant's drivers license has been forfeited, pursuant to Judicial Findings As To Forfeiture Of Licensing Privileges entered in and made a part of the record in this case. Upon application of the defendant for a limited driving privilege, the Court finds that At the time of the forfeiture of the defendant's licensing privileges, the defendant held either a valid drivers license or a drivers license 1. that had been expired less than one year. 2. The defendant: a. is supporting existing dependent(s). b. must have a drivers license to be gainfully employed. c. has an existing dependent who requires serious medical treatment and the defendant is the only person able to provide transportation to the dependent to the health care facility where the dependent can receive the medical treatment. 3. 4. The Court has been furnished a properly executed form DL-123 and is satisfied that the defendant is financially responsible. The defendant has executed form DL-123A and is not required to furnish proof of financial responsibility. It is ORDERED that the defendant be allowed a limited driving privilege to operate a non-commercial motor vehicle under the following conditions, which the Court has determined will authorize essential driving related to the purposes listed in finding number 2 above, and under no other circumstances. Geographical Restriction Driving Hours Allowed Type Of Vehicle ORDER Additional Restrictions: Corrective Lenses Other: 45 M.P.H. Only Daylight Only This Limited Driving Privilege authorizes the defendant to drive only if the defendant's license is revoked solely for a felony conviction and was ordered forfeited, and only for the duration of that revocation or for the period shown below, whichever is shorter. This Limited Driving Privilege is subject to such further orders as the Court may deem necessary and proper. It is conditioned upon the maintenance of financial responsibility. Date Of Order Effective From To Signature Of Judge Name Of Judge (Type Or Print) 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 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. Any driving not related to the purposes(s) checked above is unlawful even though done at times and upon routes that may be authorized; 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). This limited privilege does NOT authorize the operation of a commercial motor vehicle. 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 And Seal Deputy CSC Clerk Of Superior Court Materials opposite unmarked squares is to be disregarded as surplusage. Original-File Certified Copy-Defendant Copy-DMV Assistant CSC AOC-CR-318, Rev. 8/12 © 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com