OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES REPORT OF CONVICTIONS INSTRUCTIONS TO THE COURT 1. All Courts may use this form to report convictions where there is no uniform traffic ticket (UTT). Do not use this form for parking violations. 2. If the license is suspended or revoked, please send the license with this report to: Ohio Bureau of Motor Vehicles, In-State Violations, P.O. Box 16784, Columbus, OH 43216-6784. DO NOT WRITE IN DATE OF BIRTH (MONTH, DAY, YEAR) DRIVER LICENSE NUMBER THIS SPACE NAME OF DEFENDANT (LAST, FIRST, MIDDLE) ADDRESS OF DEFENDANT (STREET AND NUMBER OR RDF NUMBER) CITY OR VILLAGE COUNTY OF RESIDENCE B C D LICENSE PLATE NUMBER ZIP CODE SOCIAL SECURITY NUMBER TYPE OF DRIVER LICENSE A STATE TEMPORARY DATE OF OFFENSE IS THIS A MOVING VIOLATION YES NO SECTION OF THE LAW OR ORDINANCE VIOLATION COURT CODE Type of Vehicle Operated □ Pass □ Comm □ Cycle □ Over 26001 □ Bus □ Hazmat COURT NAME CASE NUMBER FR SHOWN TO OFFICER YES NO NO FR SHOWN TO COURT – BMV TO PROCESS SPEED OMVI YES NO YES NO LICENSE SPEED DETAIL CHILD RESTRAINT IF BOND FORFEITURE, DATE FORFEITED CONVICTION DATE MOVING VIOLATION? YES NO YES NO YES NO YES NO YES NO PLEA CODE POINTS ASSESSED BMV OFFENSE CODE IF AMENDED, OFFENSE CODE FOR BMV USE Suspension Class License Suspended _________________days/months eff. ______________________ to ______________________ MO-Limited Driving Privileges eff. _____________________ to ______________________ FRA SUSPENSION (See Separate Entry) Suspension is on Count __________________________________ License Forfeiture – See Separate BMV Form 2528 OL Confiscated – Date sent to BMV ________________________________ I hereby certify that the above statements are taken from the records of this Court. DATE: _______________________ Authorized Signature: X Send completed copy to Ohio Bureau of Motor Vehicles, P.O. Box 16784, Columbus, Ohio, 43216-6784. BMV 2718 7/07 American LegalNet, Inc. www.FormsWorkflow.com