IN THE MUNICIPAL COURT OF PERRYSBURG, WOOD COUNTY, OHIO STATE OF OHIO Plaintiff Vs. ___________________________________________ Defendant's Name CASE NO.:_____________________ PETITION FOR LIMITED DRIVING PRIVILEGES ___________________________________________ Street Address ___________________________________________ City, State, Zip ___________________________________________ Telephone Number **YOU MUST PROVIDE PROOF OF INSURANCE WITH THIS PETITION** The undersigned defendant does hereby petition the court to grant him/her the following driving privileges (Check applicable box or boxes): To and from place of employment During course of employment To and from place of schooling To and from place of treatment during the period of the driving suspension imposed by the court pursuant to: R.C. 2925 (Drug Offense) R.C. 4507.16(B) (Post Conviction Driving Suspension) R.C. 4509.101 (Non-Compliance) R.C. 4511.191 (Administrative License Suspension) R.C. 4511.196 (Judicial Suspension) or requested with a BMV reinstatement fee payment plan pursuant to R.C. 4510.10(B): Reinstatement fee associated with a Perrysburg Municipal Court case Reinstatement fee associated with a case in another court ($85 filing fee in Civil) The defendant makes the following representations to the court: (Check applicable boxes and fill in all applicable blanks) (1) He/she is presently employed as _____________________ by ______________________________________ Job Title Name of Employer located at ___________________________________________________________________________________. He/she is self-employed under the trading name of _______________________________________________ located at ___________________________________________________________________________________. (a) Days he/she works: Mon Tue Wed Thu Fri Sat Sun (b) Leave home at: __________ Arrive home at: __________ If shift work, explain: _______________________________________________________________________ (2) He/she is presently has a second job employed as __________________ by ___________________________ Job Title Name of Employer located at ___________________________________________________________________________________. (a) Days he/she works: Mon Tue Wed Thu Fri Sat Sun Arrive home at: __________ Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com (b) Leave home at: __________ Revised 02/06/2013 If shift work, explain: _______________________________________________________________________________ (3) He/she is presently enrolled as a student at _____________________________________________________ Name of School located at ___________________________________________________________________________________. (a) Days he/she attends classes: (b) Leave home at: __________ (4) Mon Tue Wed Thu Fri Sat Sun Arrive home at: __________ He/she is presently receiving treatment from ___________________________________________________ located at ___________________________________________________________________________________. (a) Days and hours of treatment vary. (5) (6) He/she is presently attending AA meetings. (a) Days, hours and locations of meetings vary. Child visitation pick up/drop off location _______________________________________________________ (a) Days of child visitation: Mon Tue Wed Thu Fri Sat Sun Arrive home at: __________ (b) Leave home at: __________ (7) Scheduled appointments for self or minor dependents at a licensed medical practitioner's place of business. (a) Days, hours and locations of appointments vary. The undersigned further represents to the court: I. II. That if the court does not grant limited driving privileges, the license suspension would seriously affect his/her ability to continue the above employment, schooling, and/or treatment. That insurance is in effect and will be kept in effect as per R.C. 4509.101. NOTICE: GIVING FALSE INFORMATION ON THIS PETITION MAY RESULT IN PERSONAL PENALTIES OF IMPRISONMENT AND/OR FINE. DATE: _________________ _____________________________________ DEFENDANT'S SIGNATURE ************************************************************************************************** **The remainder of this form will be completed by the Court** Proof of insurance was shown Denied Re-apply on _________________ _____________________________________ DATE APPROVED _____________________________________ JUDGE Please mail driving letter Defendant waiting Ignition Interlock Required Restricted Plates Required Revised 02/06/2013 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com