IN THE LORAIN MUNICIPAL COURT LORAIN, OHIO In the matter of: Name: Case No. APPLICATION FOR LIMITED DRIVING PRIVILEGES SSN/DOB: Street Address: City: Phone: I BELIEVE I AM UNDER SUSPENSION FOR THE FOLLOWING REASONS (check all that apply) O I am currently under a financial responsibility "FRA" Suspension imposed by the State of Ohio Bureau of Motor Vehicles. dl I currently owe unpaid reinstatement fees to the State of Ohio Bureau of Motor Vehicles. I owe approximately $ . YOU MUST FILL OUT THE FINANCAIL FORM OF INDIGENCY ATTACHED IF YOU SELECT THIS OPTION. I understand that either of two (2) payment plan types can be requested (choose one): EU A plan that permits payment of not less than $50.00 per month each and every month, missing no payments, until all reinstatement fees are paid in full, or A plan that permits me to defer or put off payment of all of the reinstatement fees until a future date certain but no longer than six (6) months. O I am under a points suspension "12-point" imposed by the State of Ohio Bureau of Motor Vehicles. Along with an item checked above I may need to re-new my driver's license due to expiration or re-test. 0 I am not sure why I am under suspension and I am requesting the Court's assistance to obtain limited driving privileges if possible. 1 AM REQUESTING PRIVILEGES FOR THE FOLLOWING PURPOSES: American LegalNet, Inc. www.FormsWorkFlow.com OCCUPATIONAL: Place of Employment Address City, Zip Schedule Place of Employment Address City, Zip Schedule MEDICAL REASONS: Doctor Address City, Zip Doctor Address City, Zip EDUCATIONAL: School Address City, Zip Schedule ATTEND TREATMENT: Treatment Facility/Place Address City, Zip Schedule Treatment Facility/Place Address City, Zip Schedule I further state that without driving privileges, I can not continue or improve my employment or obtain employment and, therefore, I can not support myself or my dependents all of whom are listed on my financial disclosure form. I further state that I have now and will continue to maintain a current SR-22 insurance policy or bond, a copy of which is also attached to this request. Respectfully requested, American LegalNet, Inc. www.FormsWorkFlow.com