IN THE COURT OF COMMON PLEAS OF ________________ COUNTY, PENNSYLVANIA CIVIL DIVISION Appellant vs. Commonwealth of Pennsylvania Department of Transportation Appellee : : : : : : : : : 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: Department of Transportation, Bureau of Driver Licensing, Harrisburg, Pennsylvania 17123. Department of Transportation, Bureau of Motor Vehicles, Harrisburg, Pennsylvania 17123. 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. K-1F-1.1 (Rev. 4/00) American LegalNet, Inc. www.FormsWorkflow.com 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 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.A. § 4904, relating to unsworn falsification to authorities. Date:__________________ ____________________________ Appellant -2- K-1F-1.2 (Rev. 4/00) American LegalNet, Inc. www.FormsWorkflow.com