IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA CIVIL DIVISION : : : vs. : Commonwealth of Pennsylvania : Department of Transportation File No. : PETITION FOR APPEAL FROM A SUSPENSION OF OPERATING PRIVILEGE / DENIAL OF DRIVER’S LICENSE / SUSPENSION OF MOTOR VEHICLE REGISTRATION 1. Appellant herein is , residing at and having a mailing address of : 2. Appellee herein is the Department of Transportation of the Commonwealth of Pennsylvania, having a mailing address of: PENNSYLVANIA DEPARTMENT OF TRANSPORTATION OFFICE OF CHIEF COUNSEL THIRD FLOOR, RIVERFRONT OFFICE CENTER HARRISBURG, PA 17104-2516 (Rev 3/08) 1 American LegalNet, Inc. www.FormsWorkFlow.com 3. By letter or notice dated , a copy of which is attached hereto as Exhibit A, the Department of Transportation ordered Appellant to surrender his / her operating license / motor vehicle registration for a period of . denied the issuance / renewal of a driver’s license. 4. Supersedeas: Pursuant to 75 Pa.C.S.A. § 1550(b)(1)(i), Appellant is retaining driver’s license until final determination of the suspension of operating privilege. Pursuant to 75 Pa.C.S.A. § 1550(b)(1)(ii), a hearing attended by the Appellant must be held before the Court of Common Pleas before an order of supersedeas can be issued. Pursuant to 75 Pa.C.S.A. § 1377(a), Appellant is retaining motor vehicle registration until final determination of the suspension of registration. 5. The said suspension of Appellant’s operating privileges / registration is improper or unlawful for the following reasons: Appellant respectfully requests that this matter be set down for a hearing and that the order of suspension / order of denial be set aside. Respectfully submitted by, Appellant Phone Number I verify that the statements made in this Petition are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities. Date: Appellant (Rev 3/08) 2 American LegalNet, Inc. www.FormsWorkFlow.com