IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA CIVIL DIVISION : Appellant : v s. : F ile No. Commonwealth of Pennsylvania : Department of Transportation : A ppellee . : PETITION FOR APPEAL FROM A SUSPENSIO N OF OPERATING PRIVILEGE / DENIAL OF DRIVERS LICENSE / SUSPENSION OF MOTOR VEHICHLE 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 DEPARTME NT OF TRANSPORTATION OFFICE OF CHIEF COUNSEL THIRD FLOOR, RIVERFRONT OFFICE CENTER HARRISBURG, PA 17104-2516 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 drivers license. (Rev 11/03) American LegalNet, Inc. www.USCourtForms.com>>>> 24. Supersedeas: Pursuant to 75 Pa.C.S.A. 1550(b)(1)(i), Appellant is retaining drivers 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 Appellants 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, A ppellant P hone Number I verify that the statements made in this Petition are true and correct. I understand that false statements herei nare made subject to thepenalties of 18 Pa.C.S. 904, relating to unsworn 4 falsification to authorities. Date: A ppellant 2 American LegalNet, Inc. www.USCourtForms.com