Clear.gif  
 
Worthless Check Clearance


Defendant's Name:___________________________________________________

Driver License Number:________________________________________________

SS#_______________________ Issuing County:___________________________

Warrant/Case # _______________________

 
The above warrant/capias has been cancelled/withdrawn/served by the issuing agency,and the defendant has made full payment of restitution, court costs and/or fees.
 
Date of Full Payment: _________________________
 
Check Box.gif The above warrant/capias has been cancelled/withdrawn/served, and the case is now nol-prossed or dismissed.
Check Box.gif The above warrant/capias has been cancelled/withdrawn. Issued in Error.
 
Date cancelled/withdrawn/dismissed: _____________________________
 

Authorized By:

______________________ Signature
______________________ Print or type name
__________________ Date
 
 Clerk of Court  State Attorney

(Check one or more, if applicable)

Note to customer  You must present this form to a driver license issuance office to have your driving privilege reinstated. You may be required to pay a $45.00 reinstatement fee per suspension, in addition to applicable license fees.

HSMV-72862 (R07/01)