PETITION FOR FORFEITURE
OF MOTOR VEHICLE OR VESSEL
G.L. c. 90, § 24W

CIVIL DOCKET NO.

Trial Court of Massachusetts
District Court Department

                                               District Court

DESCRIPTION OF MOTOR VEHICLE(s) OR VESSEL(s) (include year, make & model)

COMMONWEALTH  vs. __________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

LOCATION OF MOTOR VEHICLE(s) OR VESSEL(s)  (identify as particularly as possible)

VIN(s) OF MOTOR VEHICLE(s) OR VESSEL(s)

NAME & ADDRESS OF RESPONDENT (CRIMINAL DEFENDANT)

RESPONDENT’S DOB

DOCKET NO. OF CRIMINAL CASE

NAME(s) & ADDRESS(es) OF OTHER OWNERS OR OTHERS WITH APPARENT INTEREST IN MV(s) OR VESSEL(s)

POLICE DEPT(s) SUBSTANTIALLY INVOLVED 
IN FORFEITURE

Was any such motor vehicle(s) or vessel(s) jointly owned before the date of respondent’s second or subsequent qualifying
offense by a parent, spouse, child, grandparent, brother, sister, or parent of the spouse living in respondent’s household?

  9 YES   9 NO

1. As detailed below and in the attached affidavit(s), there is probable cause to believe that the motor vehicle(s) and/or

vessel(s) described above are at the location named above and are owned by the respondent named above.

2.

(Check A or B) :

9 

9 

(A)  4 prior assignments/convictions:  The respondent has at least four times been assigned to an alcohol or
controlled substance education, treatment or rehabilitation program or been convicted of a violation of G.L. c. 90,
§  24(1)(a)  or  §  24G(a),  or  of  operating  a  motor  vehicle  with  a  percentage  by  weight  of  blood  alcohol  of  eight
one-hundredths or greater or while under the influence of intoxicating liquor under § 24G(b), or of § 24L, or of G.L.
c. 90B, § 8(a), § 8A or § 8B, or of G.L. c. 265, § 13½, or of a like offense in another jurisdiction. The undersigned
hereby petitions this court in the name of the Commonwealth to order, after hearing, that the motor vehicle(s) and/or
vessel(s) described above be forfeited to the Commonwealth pursuant to G.L. c. 90, § 24W.

(B)  3 prior assignments/convictions and another pending charge:  The respondent has at least three times
been so assigned or convicted for such qualifying offenses, and a criminal complaint charging the respondent with
a fourth such qualifying offense is presently pending before this court.  The undersigned hereby petitions this court
in the name of the Commonwealth, upon such an assignment or conviction for such fourth qualifying offense, to
order, after hearing, that the motor vehicle(s) and/or vessel(s) described above be forfeited to the Commonwealth
pursuant to G.L. c. 90, § 24W.  

3. 9 

(Check  if applicable.)   Additional request for preliminary order to seize and secure.   As detailed in the attached
affidavit(s), there are also reasonable grounds to believe that it is necessary to issue a preliminary order to seize
and secure such motor vehicle(s) and/or vessel(s) and to provide for their custody during the pendency of this
petition.

DATE SIGNED

PETITIONER’S SIGNATURE 

   X

PETITIONER’S TITLE

PETITIONER’S AGENCY

  9  ASST DISTRICT ATTORNEY      9 ASST ATTORNEY GENERAL

(5/07)