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, License Verification Unit, P.O. Box 16784, Columbus, Ohio 43216-6784. DO NOT WRITE IN THIS SPACE DATE OF BIRTH (MONTH, DAY, YEAR) DRIVER LICENSE NUMBER NAME OF DEFENDANT (LAST, FIRST, MIDDLE) ADDRESS OF DEFENDANT (STREET AND NUMBER OR RDF NUMBER) CITY OR VILLAGE COUNTY OF RESIDENCE TYPE OF DRIVER LICENSE A B C D LICENSE PLATE NUMBER STATE ZIP CODE SOCIAL SECURITY NUMBER TEMPORARY DATE OF OFFENSE IS THIS A MOVING VIOLATION YES NO SECTION OF THE LAW OR ORDINANCE VIOLATION COURT CODE COURT NAME FR SHOWN TO OFFICER YES NO NO FR SHOWN TO COURT – BMV TO PROCESS CASE NUMBER TYPE OF VEHICLE OPERATED PASS COMM SPEED OMVI LICENSE YES NO YES NO CYCLE OVER 26001 CHILD RESTRAINT BUS HAZMAT SPEED DETAIL 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 ______________________ (See Separate Entry) Suspension is on Count __________________________________ FRA Suspension 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. X AUTHORIZED SIGNATURE SEND TO: BMV 2327 2/11 DATE Ohio Bureau of Motor Vehicles, License Verification Unit, P.O. Box 16784, Columbus, Ohio 43216-6784 American LegalNet, Inc. www.FormsWorkFlow.com