STATE OF NORTH CAROLINA County Name And Address File No. In The General Court Of Justice District Court Division IN THE MATTER OF REVOCATION ORDER WHEN PERSON PRESENT FINDINGS FOR PROBABLE CAUSE G.S. 20-16.5 The undersigned judicial official finds probable cause to believe that: 1. A law enforcement officer had reasonable grounds to believe that the above-named person committed an offense subject to the implied-consent provisions of G.S. 20-16.2; 2. The above-named person has been charged with that offense as provided in G.S. 20-16.2(a); 3. Both the law enforcement officer and the chemical analyst(s) complied with the provisions of G.S. 20-16.2 and 20-139.1 in requiring the above-named person's submission to or procuring a chemical analysis; and 4. The above-named person: a. willfully refused to submit to a chemical analysis. b. had an alcohol concentration of 0.08 or more at any relevant time after the driving. c. had an alcohol concentration of 0.04 or more at any relevant time after the driving of a commercial motor vehicle. d. had any alcohol concentration at any relevant time after the driving, and at the time of the offense, was under 21 years of age. 5. The above-named person has one or more pending offenses in the following county(ies) for which the person's drivers license had been or is revoked under G.S. 20-16.5. Date It is ORDERED that the above-named person's drivers license or privilege to drive be revoked. The above-named person is prohibited from operating a motor vehicle on the highways of North Carolina during the period of revocation. The revocation remains in effect at least thirty (30) days from: 1. this date 2. the date he/she surrenders his/her drivers license or privilege to drive to the Court, or demonstrates that he/she is not currently licensed to drive. 3. (check this option if Findings For Probable Cause No. 5 above is checked) the date he/she surrenders his/her drivers license or privilege to drive to the Court, or demonstrates that he/she is not currently licensed to drive and indefinitely until a final judgment, including appeals, has been entered for the current offense and for all pending offenses for which his/her drivers license or privilege to drive had been or is revoked under G.S. 20-16.5. The above-named person's privilege to drive in North Carolina is revoked and will remain revoked until the person has actually surrendered his/her license for the period specified above and has paid a $100 fee to the Clerk of Superior Court. I informed the above-named person of his/her rights to a hearing and gave him/her a copy of this Order. ORDER Name Of Judicial Official (Type Or Print) Signature Of Judicial Official Judge Assistant CSC NOTE: See reverse for supplemental findings and order, and for disposition of license. If at the time of this Order you have only a temporary driving certificate, you must surrender the certificate, and then you also must surrender your license card immediately when you later receive it in the mail from DMV. If at the time of this Revocation you were not licensed to drive by the North Carolina Division of Motor Vehicles and did not have a valid drivers license from another state, an additional $50 restoration fee must be paid to the Division of Motor Vehicles before you can drive again in North Carolina.This fee must be paid even though you are a resident of another state. You have a right to a hearing to contest the validity of this Revocation before a magistrate or judge. To do so, a written request must be made within ten (10) days of the effective date of the revocation. A hearing request form is available from the office of the Clerk of Superior Court or magistrate. Your license will remain revoked and you are not authorized to drive pending the hearing. If you do request a hearing but fail to appear, you forfeit the right to a hearing. If your license is revoked under Paragraph 1 or 2 of this Order, at the end of the revocation period you are still prohibited from driving until you have paid a fee of $100 to the Clerk of Superior Court. If your license is revoked under Paragraph 3 of this Order, that revocation remains in effect at least thirty (30) days and until a final judgment, including appeals, is entered for this current offense and for all pending offenses for which your license has been or is revoked under G.S. 20-16.5. At the end of the revocation period you are still prohibited from driving until you have paid a fee of $100 to the Clerk of Superior Court. This fee is in addition to any fee you have paid or are to pay in connection with any other pending offense for which your drivers license has been revoked under G.S. 20-16.5. The $100 fee may be paid at any time, even prior to the end of the period of revocation, between the hours of 8:30 a.m. and 5:00 p.m., Monday through Friday. Payment in person must be made in cash or by certified check, cashier's check or money order. Payment by mail must be made by certified check, cashier's check or money order, payable to the Clerk of Superior Court. If you wish to have your drivers license returned to you by mail, please enclose a stamped, self-addressed envelope with your payment. IT IS UNLAWFUL FOR YOU TO DRIVE A MOTOR VEHICLE IN THE STATE OF NORTH CAROLINA UNTIL YOU ARE AUTHORIZED TO DO SO. THE DIVISION OF MOTOR VEHICLES MAY ALSO DISQUALIFY YOU FROM OPERATING A COMMERCIAL MOTOR VEHICLE UNDER G.S. 20-17.4. AOC-CVR-2, Rev. 4/14 © 2014 Administrative Office of the Courts Original-File Copy-Person Whose License Revoked (Over) American LegalNet, Inc. www.FormsWorkFlow.com NOTICE Magistrate Clerk Of Superior Court Deputy CSC It is ORDERED that this Revocation of the drivers license of the person named herein: remains 1. the Clerkinofeffect for at least thirty (30) days from the above date and until payment of a $100 fee has been made to Superior Court. is indefinite effect 2. (30) days from the above date and until a final judgment, including appeals, hasand remains infor the for at least thirty been entered current offense (check this option if Findings For Probable Cause No. 5 on reverse side is checked) SUPPLEMENTAL FINDINGS AND ORDER It is further found that the person named herein appeared before the undersigned judicial official at AM PM on this day of , , and, 1. surrendered his/her drivers license to the Court. 2. was validly licensed but unable to locate his/her license card and filed an affidavit which constituted surrender of the drivers license.