STATE OF SOUTH CAROLINA ) IN THE COURT OF ) GENERAL SESSIONS ) ______Judicial Circuit County of ___________________ ) ) STATE OF SOUTH CAROLINA ) Petitioner ) )VEHICLE IMMOBILIZATION Vs. ) ) ___________________________ )Case Number______-GS-____-_______ Defendant ) Date of Birth_________________ ) SCDL #_____________________ Pursuant to S.C. Code Ann. 56-5-2942(J), you are required to surrender all license plates and vehicle registration numbers to the Department of Motor Vehicles so that all vehicles registered to or owned by you may be immobilized as a result of this conviction. Upon notification from the DMV, you must surrender the license plates from all vehicles listed below as required by law. Please list the make and model of each vehicle registered in your name, the corresponding license plate number and vehicle registration number of each vehicle. Vehicle Make and Model License Plate Number Registration Number I hereby certify that the information I have provided is true, accurate, and complete under penalty of perjury in accordance with S.C. Code Ann. 16- 9-10. _________________________________ _______________________________ Defendant Date American LegalNet, Inc. www.USCourtForms.comSCCA / 220 (01/04)