American LegalNet, Inc. www.FormsWorkFlow.com CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of the Suspension ) of the Driving Privileges of ) . ) PETITION FOR JUDICIAL ) REVIEW , ) Petitioner ) DMV No. ) v. ) Circuit Court ) Case No. Driver and Motor Vehicle Services Branch of the ) Oregon Department of Transportation (DMV), ) Respondent. ) PETITION FOR JUDICIAL REVIEW OF ORDER OF DMV Petition seeks judicial review of the final order of suspension of driving privileges entered by the administrative law judge of the DMV in case number , date . Parties to this review are: (set out petitioner's full name and address) And, Driver and Motor Vehicle Services Branch of the Oregon Department of Transportation (DMV) The Order of the DMV should be vacated because evidence in the record fails to substantially support the administrative law judge222s finding that the following requirements were met (check those items that apply): (a) The petitioner, at the time the petitioner was requested to submit to a test under ORS 813.100, was under arrest for driving while under the influence of intoxicants in violation of ORS 813.010 or a municipal ordinance. (b) The police officer had reasonable grounds to believe, at the time the request was made, that the petitioner had been driving under the influence of intoxicants in violation of ORS 813.010 or a municipal ordinance. Page 1 - Form 10.010.a 226 PETITION FOR JUDICIAL REVIEW OF ORDER OF DMV 226 UTCR 10.010 (Revised 8-1-09) TCG-5-F1 American LegalNet, Inc. www.FormsWorkFlow.com (c) The petitioner refused to test under ORS 813.100 or took the test and the test disclosed that the level of alcohol in the petitioner's blood was sufficient to constitute being under the influence of intoxicating liquor under ORS 813.300. (d) The petitioner had been informed under ORS 813.100 of the rights and consequences as described under ORS 813.100. (e) The petitioner was given written notice required under ORS 813.100. (f) If the petitioner submitted to the test, the person administering the test was qualified to administer the test under ORS 813.160. (g) If the petitioner submitted to the test, the methods, procedures and equipment used in the test complied with requirements under ORS 813.160. (h) Other: Dated this day of , 20 . Set out name, OSB number (attorneys only), address and telephone number G Petitioner G Attorney for Petitioner (Please check one of the above) Page 2 - Form 10.010.a 226 PETITION FOR JUDICIAL REVIEW OF ORDER OF DMV 226 UTCR 10.010 (Revised 8-1-09) TCG-5-F1