OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES REPORT OF CONVICTIONS INSTRUCTIONS TO THE COURT 1. 2. 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. 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. DATE OF BIRTH (MONTH, DAY, YEAR) DRIVER LICENSE NUMBER DO NOT WRITE IN THIS SPACE NAME OF DEFENDANT (LAST, FIRST, MIDDLE) ADDRESS OF DEFENDANT (STREET AND NUMBER OR RDF NUMBER) CITY OR VILLAGE TYPE OF DRIVER LICENSE A B C D LICENSE PLATE NUMBER TEMPORARY DATE OF OFFENSE IS THIS A MOVING VIOLATION YES SECTION OF THE LAW OR ORDINANCE VIOLATION COURT CODE FR SHOWN TO OFFICER YES NO COURT NAME NO FR SHOWN TO COURT ­ BMV TO PROCESS SPEED TYPE OF VEHICLE OPERATED PASS OMVI COMM LICENSE CYCLE OVER 26001 CHILD RESTRAINT BUS HAZMAT SPEED DETAIL CASE NUMBER NO COUNTY OF RESIDENCE STATE SOCIAL SECURITY NUMBER ZIP CODE IF BOND FORFEITURE, DATE FORFEITED CONVICTION DATE MOVING VIOLATION? PLEA CODE POINTS ASSESSED BMV OFFENSE CODE IF AMENDED, OFFENSE CODE FOR BMV USE YES NO YES NO YES NO YES NO YES NO YES NO YES NO 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 Waive Probationary 2 or Probationary 3 Suspension (Ohio Revised Code 4510.31) Court Ordered Parent / Guardian Restriction eff. to I hereby certify that the above statements are taken from the records of this Court. AUTHORIZED SIGNATURE DATE X SEND TO: Ohio Bureau of Motor Vehicles, License Verification Unit, P.O. Box 16784, Columbus, Ohio 43216-6784 BMV 2327 7/15 [760-0271] RESTRICTED American LegalNet, Inc. www.FormsWorkFlow.com