File No. STATE OF NORTH CAROLINA In The General Court Of Justice Superior Court Division District County STATE VERSUS Name And Address Of Applicant LIMITED DRIVING PRIVILEGE WILLFUL REFUSAL Race Sex Height Hair Color Eye Color Date Of Birth Weight G.S. 20-16.2 Drivers License No. State Offense Charged Date Of Refusal FINDINGS Upon application for a limited driving privilege, by an applicant whose drivers license was revoked for twelve (12) months for willful refusal to submit to a chemical analysis after being charged with an implied-consent offense, the Court finds that: 1. At the time of the refusal, the applicant held either a valid drivers license, or a drivers license that had been expired for less than one year; 2. At the time of the refusal, the applicant had not within the preceding seven (7) years been convicted of an offense involving impaired driving; 3. At the time of the refusal, the applicant had not in the preceding seven (7) years willfully refused to submit to a chemical analysis under G.S. 20-16.2; 4. The implied-consent offense did not involve death or critical injury to another person; 5. The underlying charge for which the applicant was requested to submit to a chemical analysis was finally disposed of (a) other than by conviction or (b) by a conviction of impaired driving under G.S. 20-138.1 at a punishment level authorizing issuance of a limited driving privilege under G.S. 20-179.3(b), and the applicant has complied with at least one of the mandatory conditions of probation listed for the punishment level under which he/she was sentenced, or (c) by a conviction of impaired driving under G.S. 20-138.2; 6. Subsequent to the refusal, the applicant has had no unresolved pending charges for, or additional convictions of, an offense involving impaired driving; 7. The applicant's drivers license has been revoked for at least six (6) months for the refusal; 8. The records of the Division of Motor Vehicles and the Clerk of Superior Court in this county have been searched, and there are no revocations in effect other than a revocation under G.S. 20-16.2 for this willful refusal, and a revocation imposed under G.S. 20-17(a)(2), for the underlying charge; 9. The defendant has obtained a substance abuse assessment and has successfully completed any recommended training or treatment program; and has filed with the Clerk a certificate of completion; (Mandatory for offenses committed on or after December 1, 1997.) 10. 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; (If this item is selected, the restrictions in G.S. 20-179.3(g5) apply to the defendant. If the offense was committed on or after December 1, 2007, the defendant is also subject to the restrictions in G.S. 20-179.3(c1).) 11. a. The Court has been furnished a properly executed form DL-123 and is satisfied that the defendant is financially responsible. b. The defendant has executed form DL-123A and is not required to furnish proof of financial responsibility. ORDER It is ORDERED that the applicant be allowed a limited driving privilege to be effective from the date of this Order, to be used in accordance with the restrictions imposed in this form, and to expire twelve (12) months from the date on which the Division of Motor Vehicles notified the defendant that the defendant's drivers license was revoked pursuant to G.S. 20-16.2(d). The 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. Date Name Of Judge (Type Or Print) AOC-CR-313, Rev. 12/07 © 2007 Administrative Office of the Courts Original-File Signature Of Judge 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 restricted to: a. any non-commercial vehicle registered in the name of the driver. b. the following non-commercial vehicle(s): The above vehicle shall be equipped with a functioning ignition 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. The driver may drive to and from any ignition interlock service facility for installation and service purposes. 5. Additional restrictions: Corrective Lenses Name And Address Of Community Service Coordinator To Which Driver Assigned 45 M.P.H. Only Daylight Only Other: 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 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 I drive with the odor of alcohol on my breath, I may be subject to arrest and loss of this limited driving privilege; 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 Applicant CERTIFICATION I certify that this is a true and complete copy of the original on file in this case. Date Signature Assistant CSC Deputy CSC Clerk Of Superior Court AOC-CR-313, Side Two, Rev. 12/07 © 2007 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkflow.com