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STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY
CERTIFICATION TO
DEPARTMENT OF STATE
(INTERLOCK PROGRAM)
Part 1
CASE NO. and JUDGE
Court address
Court telephone no.
THE PEOPLE OF
The State of Michigan
TO: Department of State
Defendant’s name, address, and telephone no.
v
Driver’s License No.
CTN/TCN
DOB
SID
1. The defendant has been admitted into the DWI/sobriety court program; and an approved, certified ignition interlock
device has been installed in each motor vehicle owned or operated, or both, by the defendant as required under
MCL 257.625k and MCL 257.625l.
2. Travel
is
is not
allowed under MCL 257.304(4)(b)(xi).
3. The defendant has successfully completed the DWI/sobriety court program.
4. Under MCL 600.1084(6), the Secretary of State is informed that:
a. the court ordered that the defendant be removed from the DWI/sobriety court program before he or she
successfully completed it.
b. the court became aware that the defendant operated a motor vehicle that was not equipped with an interlock
device.
c. the court became aware that the defendant
tampered with
circumvented
removed
a court-ordered interlock device without prior court approval.
d. the defendant was charged with a new violation of MCL 257.625.
5. The interlock device was removed from the defendant’s vehicle because:
Judge signature and date
Approved, SCAOForm MC 393, Rev. 5/21MCL 257.304, MCL 600.1084Page 1 of 1Distribute form to:Court (Part 2)Department of State (Part 1) STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY
CERTIFICATION TO
DEPARTMENT OF STATE
(INTERLOCK PROGRAM)
Part 2
CASE NO. and JUDGE
Court address
Court telephone no.
THE PEOPLE OF
The State of Michigan
TO: Department of State
Defendant’s name, address, and telephone no.
v
Driver’s License No.
CTN/TCN
DOB
SID
1. The defendant has been admitted into the DWI/sobriety court program; and an approved, certified ignition interlock
device has been installed in each motor vehicle owned or operated, or both, by the defendant as required under
MCL 257.625k and MCL 257.625l.
2. Travel
is
is not
allowed under MCL 257.304(4)(b)(xi).
3. The defendant has successfully completed the DWI/sobriety court program.
4. Under MCL 600.1084(6), the Secretary of State is informed that:
a. the court ordered that the defendant be removed from the DWI/sobriety court program before he or she
successfully completed it.
b. the court became aware that the defendant operated a motor vehicle that was not equipped with an interlock
device.
c. the court became aware that the defendant
tampered with
circumvented
removed
a court-ordered interlock device without prior court approval.
d. the defendant was charged with a new violation of MCL 257.625.
5. The interlock device was removed from the defendant’s vehicle because:
Judge signature and date
Approved, SCAOForm MC 393, Rev. 5/21MCL 257.304, MCL 600.1084Page 1 of 1Distribute form to:Court (Part 2)Department of State (Part 1)
MC 393, Certification to Department of State (Interlock Program)
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