Administrative Hearing Request Safety Responsibility Suspension Form - Illinois

This "Administrative Hearing Request Safety Responsibility Suspension Form" is a Illinois-specific form released by the Illinois Secretary of State on August 1, 2018.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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Office of the
Secretary of State
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
ADMINISTRATIVE HEARING REQUEST
Support Services Division
Room 212, Howlett Building
SAFETY RESPONSIBILITY SUSPENSION
Springfield, IL 62756
www.cyberdriveIllinois.com
Department of Transportation Crash #:
Secretary of State File #:
Date of Accident:
Illinois Driver’s License #:
Illinois Registration #:
Effective Date of Suspension:
I,
____________________________________________________________________________ hereby request an
Administrative Hearing pursuant to 625 ILCS 5/7-205, Illinois Revised Statutes.
Please note that any request for a hearing to contest a Safety Responsibility Suspension must be
accompanied by a $50 filing fee. The fee must be submitted in the form of a money order, cashier’s or certified
check,or an attorney’s check,payable to Secretary of State. Payment also may be made by credit card by completing
the form on the reverse. CASH OR PERSONAL CHECKS ARE NOT ACCEPTED.
If a request is received without the filing fee the form will be returned and a hearing will not be scheduled. This fee
is non-refundable in accordance with Section 2-118 of the Illinois Vehicle Code and 92 Illinois Administrative Code
1001.220.
I/We are aware that these Administrative Hearings are conducted at locations throughout Illinois, with location for
said hearing determined by the uninsured motorist’s county of residence.
Signature ________________________________________________________________________
Street Address ____________________________________________________________________
City, State, ZIP Code ________________________________________________________________
Email Address ____________________________________________________________________
Date ____________________________________________________________________________
Printed by authority of the State of Illinois. August 2018 — 1 — DAH H-74.7
Print
Reset
Office of the
Secretary of State
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
ADMINISTRATIVE HEARING REQUEST
Support Services Division
Room 212, Howlett Building
SAFETY RESPONSIBILITY SUSPENSION
Springfield, IL 62756
www.cyberdriveIllinois.com
Department of Transportation Crash #:
Secretary of State File #:
Date of Accident:
Illinois Driver’s License #:
Illinois Registration #:
Effective Date of Suspension:
I,
____________________________________________________________________________ hereby request an
Administrative Hearing pursuant to 625 ILCS 5/7-205, Illinois Revised Statutes.
Please note that any request for a hearing to contest a Safety Responsibility Suspension must be
accompanied by a $50 filing fee. The fee must be submitted in the form of a money order, cashier’s or certified
check,or an attorney’s check,payable to Secretary of State. Payment also may be made by credit card by completing
the form on the reverse. CASH OR PERSONAL CHECKS ARE NOT ACCEPTED.
If a request is received without the filing fee the form will be returned and a hearing will not be scheduled. This fee
is non-refundable in accordance with Section 2-118 of the Illinois Vehicle Code and 92 Illinois Administrative Code
1001.220.
I/We are aware that these Administrative Hearings are conducted at locations throughout Illinois, with location for
said hearing determined by the uninsured motorist’s county of residence.
Signature ________________________________________________________________________
Street Address ____________________________________________________________________
City, State, ZIP Code ________________________________________________________________
Email Address ____________________________________________________________________
Date ____________________________________________________________________________
Printed by authority of the State of Illinois. August 2018 — 1 — DAH H-74.7
Office of the Secretary of State
Department of Administrative Hearings
Rm. 212, Howlett Building
Springfield, IL 62756
217-782-7065
CREDIT OR DEBIT CARD PAYMENT FORM
To use a Visa, Novus/Discover, American Express or Mastercard as a method of payment for the Hearing filing fee,
please complete the information below. If paying by check, money order or attorney’s check, do not com-
plete this form.
The credit/debit card must have a valid expiration date and a good credit standing. A payment processor fee will be
assessed to the total for credit/debit charges. (This fee is charged by the bank. NO portion is retained by the
Secretary of State.)
Credit
Debit
Petitioner’s Name
Driver’s License Number
Street Address
City, State, ZIP Code
Daytime Telephone Number
Please check the appropriate card
(
)
Cardholder’s Name (as it appears on card)
SM
S
Cardholder’s Credit/Debit Card Number
Expiration Date
Security Code
123
(3 on back: AMEX-4 on front)
1234
Cardholder’s Mailing Address
City
State
ZIP
I hereby authorize the Office of the Secretary of State to charge my credit/debit card account for payment to be
rendered plus the processor fee.
___________________________________________________________________________________________________________
__________________________________________________
Date
Cardholder’s Signature
___________________________________________________________________________________________________________
__________________________________________________
Date
Petitioner’s Signature

Download Administrative Hearing Request Safety Responsibility Suspension Form - Illinois

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