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Worthless Check - Hardship License Request
 
Name:________________________________

Florida DL#____________________________
SS#___________________________________

Telephone#_____________________________
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.
 

__________________________________
(Signature)

_________________________________
(Date)
 
  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: ___________________________________
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Authorized By: ______________________  _______________________
  (Signature) (Print or type name)

Authorized Agency:
Check BoxClerk of Court
Check BoxState Attorney

County ______________________________________________
Court Seal
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  To Be Completed by Clerk of Court in the defenant'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: _______________________

___________________________________________________________

COUNTY:____________________________________________________

AUTHORIZED
 ______________________________
(Signature)
_____________________
(Date)
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.