1. I request a review of the action of the Secretary of State dated 
  suspension, restriction, or denial of my driving privileges.

Date

 that resulted in 

2. I am appealing the 
  MCL 257.323(2).

 

 record pursuant to MCL 257.323(4). 

 

 findings of a license appeal hearing pursuant to 

3. The action should be set aside because it was
 
 
 
 
 
 
 

 in violation of the constitution of the United States, the state constitution of 1963, or a statute as described below.
 in excess of the Secretary of State’s  statutory authority or jurisdiction as described below.
 made upon unlawful procedure resulting in material prejudice to the petitioner as described below.
 not supported by competent, material, and substantial evidence on the whole record as described below.
 arbitrary, capricious, or clearly an abuse or unwarranted exercise of discretion as described below.
 affected by other substantial and material error of law as described below.

(Provide details for each of the boxes that are checked. If necessary attach separate sheets.)

4. I request that the driving record/transcript be prepared by the Secretary of State pursuant to MCL 257.323(1) and filed 
  with the court, and that upon review of the record, the court set aside the Secretary of State’s action for the grounds 
  stated above.

Date

 

Signature of petitioner

Approved, SCAO
Form CC 295, Rev. 5/21
MCL 257.323, MCL 257.323a-c
Page 1 of 2

Distribute form to: 
Court 
Secretary of State 
Petitioner
Attorney General/Prosecutor

STATE OF MICHIGANJUDICIAL CIRCUITCOUNTYAPPEAL OF SUSPENSION, REVOCATION, ORDENIAL OF DRIVER’S LICENSECASE NO. and JUDGECourt addressCourt telephone no.Petitioner’s name, address, and telephone no.vRespondent SECRETARY OF STATE OF THE STATE OF MICHIGAN Driver Assessment and Appeal Division PO Box 30196 Lansing, Michigan 48909-7696Driver’s license no. Put DLN in Ref. No. row 10 on MC 97a.Date of birth Put DOB in Ref. No.  row 10 on MC 97a.Petitioner’s attorney, bar no., address, and telephone no.Respondent’s attorney, bar no., address, and telephone no.Appeal of Suspension, Revocation, or Denial of Driver’s License 
Page 2 of 2

(5/21) 

Case No. 
 

IT IS ORDERED:

ORDER FOR HEARING

A hearing on the petition shall be held on 

at 

 

 the court address above. 

 

Date and time

 
Location

 

                     

Judge signature and date

CERTIFICATE OF MAILING

I served a copy of this appeal and order for hearing on the parties or their attorneys by first-class mail addressed to their 
last-known addresses as defined by MCR 2.107(C)(3). I declare under the penalties of perjury that this certificate of mailing 
has been examined by me and that its contents are true to the best of my information, knowledge, and belief.

Date

 

Signature of petitioner