1. I request a review of the following action of the Secretary of State dated 
  suspension, restriction, or denial of my driving privileges.
 
 
 
 
 
2. I am in need of driving privileges and will suffer undue hardship if relief from the Secretary of State action is not granted 
   because: (Provide details. If necessary attach separate sheets.)

 a. Application denial for medical reasons (MCL 257.303[1][d]).
 b. Driver assessment suspension or restriction (not a revocation) (MCL 257.310d, MCL 257.320).
 c.  First implied consent suspension (MCL 257.625f).
 d. Mandatory additional suspension or revocation for driving while license suspended (MCL 257.904[10]).
 e. The arrest or action took place before January 1, 1992.

 that resulted in 

Date

license.

3. I am not requesting a restricted license that would permit a person to drive a vehicle that requires a commercial driver’s 
 
4. Except for the action I am asking the court to review, I have no other suspensions, revocations, restrictions, or denials of 
  my privilege to drive that would be inconsistent with the relief sought in this petition.
5. I request 

  driving privileges.

 restricted 

 full 

 

 

Date

 

Signature of petitioner

Approved, SCAO
Form CC 296, 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 CIRCUITCOUNTYPETITION FOR REVIEW OF DRIVER’SLICENSE DENIAL, RESTRICTION, OR SUSPENSION FOR ARRESTS OR ACTIONS BEFORE OCTOBER 1, 1999CASE 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.Petition for Review of Driver’s License Denial, Restriction, or Suspension 
(For Arrests or Actions Before October 1, 1999)
Page 2 of 2

(5/21) 

Case No. 
 

ORDER FOR HEARING

IT IS ORDERED:

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 petition 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