IN THE DELAWARE MUNICIPAL COURT, DELAWARE COUNTY, OHIO (FULL NAME - PLEASE PRINT) (ADDRESS) (CITY) (STATE) (ZIP) Petitioner, -vsRegistrar Ohio Bureau of Motor Vehicles P. O. Box 16520 Columbus, Ohio 43216 Respondent. Case No. __________________________________ COMPLAINT - POINTS ONLY 1. State Bureau Case No. 2. Now comes the Petitioner and says that he/she received a letter suspending his/her driver’s license, effective . 3. Petitioner can show cause why the suspension should be set aside or modified (circle one). (Affidavit is set forth on reverse side). 4. Petitioner agrees to pay court costs. 5. Petitioner asks that Respondent, Registrar, send to Petitioner a copy of points accumulated. (PETITIONER’S SOCIAL SECURITY NUMBER) (PETITIONER/ATTORNEY SIGNATURE) (OPERATOR LICENSE NUMBER) (PRINT FULL NAME) (PHONE NUMBER) (ADDRESS) (CITY) (STATE) (ZIP) CERTIFICATE OF SERVICE: A copy of this complaint has been served on the Respondent, by certified mail, this day of ,2 . Cindy Dinovo, Clerk of Court By: Deputy Clerk Revised February 26, 2008 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT IN SUPPORT OF COMPLAINT The undersigned Affiant states that the points assessed against his/her license by the Bureau of Motor Vehicles are not accurate because: Further, Affiant states in support of modification that: 1. His/Her residence address is and is located in County, Ohio. 2. His/Her place of employment is and is located at 3. His/Her work hours are 4. Driving privileges during work are / are not necessary because: 5. Self-Employed / Company Car / Company Truck (circle if appropriate). 6. Other: Petitioner/Affiant State of Ohio County of Delaware, ss: Sworn to and subscribed before me, a Notary Public or Deputy Clerk of this Court, this ,2 . day of Notary Public/Deputy Clerk of Court Revised February 26, 2008 American LegalNet, Inc. www.FormsWorkflow.com