Worthless Check - Hardship License Request

Florida DL#____________________________



Where you can be reached between 8:00 a.m. and 5:00 p.m.
Mailing Address____________________________________________________________________

I hereby request an Administrative Hearing to be considered for hardship reinstatement of my driving privilege.



  To Be Completed By Clerk of Court or State Attorney
  Defendant's Name_________________________________________________________________

SS#______________________________   Warrant/Case#________________________________

Check Box Defendant has agreed to make restitution pursuant to the terms and conditions set forth by the court.
Check Box Defendant has established a court date for this case.      Court date: ___________________________________
Authorized By: ______________________  _______________________
  (Signature) (Print or type name)

Authorized Agency:

Check BoxClerk of Court

Check BoxState Attorney

County ______________________________________________
Court Seal
  To Be Completed by Clerk of Court in the defendant's resident county

The Above Named Individual:

Check Box Has no traffic cases pending in this county for the past 30 days.
Check Box Has the following traffic cases pending: _______________________





Court Seal

Note to Customer:  Please mail or fax this completed form to the Division of Driver Licenses, Bureau of Administrative Reviews. You will be contacted for a brief telephonic hearing.