File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division County STATE VERSUS Name Of Defendant ORDER TO SURRENDER LICENSE OR LIMITED DRIVING PRIVILEGE State Drivers License No. G.S. 20-16.1, 20-17.8, 20-20.1, 20-179.3 FINDINGS FOR PROBABLE CAUSE The undersigned judicial official finds probable cause to believe that: 1. A charging officer had reasonable grounds to believe that the above named person committed the offense of driving while license revoked in that the above named person a. is subject to the restrictions of G.S. 20-17.8 and violated one or more of those restrictions. b. holds a limited driving privilege pursuant to G.S. 20-16.1, 20-20.1, or 20-179.3 and violated one or more of the restrictions included in the limited driving privilege order. 2. The above named person has been charged with driving while license revoked. ORDER It is ORDERED that the above named person's drivers license or limited driving privilege be suspended, and the above named person is prohibited from operating a motor vehicle on the highways of North Carolina until the case is resolved and the person is authorized to drive by the Division of Motor Vehicles. It is further ORDERED that the above named person immediately surrender the person's drivers license or limited driving privilege to the court. I informed the above named person that the person is not entitled to drive until the case is resolved. Date Name Of Judicial Official (Type Or Print) Signature Of Judicial Official Judge Magistrate NOTICE Your drivers license or limited driving privilege is suspended. Your license or limited driving privilege will remain suspended until the case is resolved. It is unlawful for you to drive a motor vehicle in the state of North Carolina until you are authorized to do so. ACKNOWLEDGMENT I understand that my drivers license or limited driving privilege is suspended as of the date of this receipt and I also understand that the law forbids me to drive a motor vehicle upon the highways while my license or limited driving privilege is suspended. I have read and understand the contents of this document and do hereby acknowledge receipt of a copy. Date Signature Of Defendant 1 - NC License Surrendered 3 - Lost License or Lost Limited Driving Privilege 2 - Limited Driving Privilege Surrendered The drivers license or limited driving privilege described above was received on the date below. Date Name Of Judicial Official (Type Or Print) AOC-CR-341, Rev. 12/07 © 2007 Administrative Office of the Courts Signature Of Judicial Official Deputy CSC Assistant CSC CSC Magistrate Original - File Copy - Person Whose License Suspended American LegalNet, Inc. www.FormsWorkflow.com