Free State of Minnesota - Minnesota

State of Minnesota
County Judicial District: Court File Number: Case Type:

District Court
Other Civil

______________________________, Petitioner vs.

Petition for Court Hearing on Reinstatement of Driver's License Minn. Stat. § 171.19

Commissioner of Public Safety, Respondent

Petitioner petitions this Court for reinstatement of his/her driving privileges pursuant to Minn. Stat. §171.19 and states as follows: 1. My name is and I currently live at (address) in _ (County). 2. On or about _____________________ (date), I received notice from the Department of Public Safety, Driver and Vehicle Services Division, that stated my driver's license will be or was (check the box that applies) refused suspended revoked cancelled disqualified, effective

(date), for a period of __________(days/year). 3. The notice states that my license was taken because

and that the incident occurred in (name of city)

4.

For the license problem described at #2 and #3: This is the first time I have filed a court Petition for reinstatement of my driving license OR

CIV111

State

Eng

4/09

www.mncourts.gov/forms

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I previously filed a Petition and the court denied my request to get my driver's license reinstated. The hearing date was (mo/day/yr)______________and today is at least 1 year since the hearing date. (If it is less than one year, you cannot file now.) 5. 6. 7. My date of birth is _____________________________________. My driver's license number is ____________________________________. I believe that my license should be reinstated because

8. I am filing this petition within 180 days of the effective date of the order of revocation, suspension, cancellation, disqualification or refusal notice. I am filing this petition before the expiration date of the revocation, suspension, cancellation, disqualification or refusal.

Wherefore, petitioner seeks judgment of this Court as follows: 1. Reinstatement of petitioner's driving privileges pursuant to Minn. Stat. §171.19. 2. For such other and further relief as the Court deems just and proper.

Dated: Signature of Petitioner, pro se (Sign only in front of notary public or court administrator.) Name: Sworn/affirmed before me this day of , Address City/State/Zip: Telephone: ( Notary Public \ Deputy Court Administrator )

CIV111

State

Eng

4/09

www.mncourts.gov/forms

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