Documentation of Non-traditional Support/Recovery Program - Illinois

The Illinois Secretary of State has released this version of the "Documentation of Non-traditional Support/Recovery Program" on April 1, 2015.

This form may be used by all Illinois residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Office of the
DOCUMENTATION OF NON-TRADITIONAL
Secretary of State
SUPPORT/RECOVERY PROGRAM
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
Additional forms may be obtained at
www.cyberdriveillinois.com
A petitioner must provide written documentation of a support/recovery program that does not involve a structured, organized and
recognized program, such as Alcoholics Anonymous, Narcotics Anonymous, consisting of at least three original letters from
participants of the program. This form may be completed and submitted in lieu of a letter. Letters/forms must be signed and
dated within 45 days if appearing in person for a hearing. If being submitted as part of a Non-Resident Out-of-State Hearing
Application, the letters/forms must be signed and dated within 45 days of the postmark date. If additional space is needed, please
use the back of this form.
IMPORTANT: In addition to the minimum three letters, a petitioner must submit a personally prepared letter that
specifically identifies and explains what his/her support/recovery program consists of, who its members/participants
are, and how both the program and the fellow members/participants help him/her remain abstinent. The letter must
be in its original form, signed and dated within 45 days prior to being mailed to the Illinois Secretary of State’s office.
____________________________________________________
____________________________________________________
Petitioner’s Name (type or print)
Illinois Driver’s License Number
1.
What is your relationship to the petitioner (family member, friend, co-worker, etc.)?
2.
How long have you known the petitioner?
3.
How often do you see the petitioner (daily, weekly, monthly, etc.)?
4.
How are you involved in the petitioner’s support/recovery program, and how does that help the petitioner remain abstinent?
5.
If you knew the petitioner while he/she was actively drinking/using, what has changed that now enables you to help him/her
remain abstinent?
6.
What changes have you seen in the petitioner since he/she has been involved in this support/recovery program?
____________________________________________________
____________________________________________________
Signature
Date
__________________________________________________________________________________________________________
Address/City/State/ZIP
Printed by authority of the State of Illinois. April 2015 — 5M — DAH IH 67.4
Print
Reset
Save
Office of the
DOCUMENTATION OF NON-TRADITIONAL
Secretary of State
SUPPORT/RECOVERY PROGRAM
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
Additional forms may be obtained at
www.cyberdriveillinois.com
A petitioner must provide written documentation of a support/recovery program that does not involve a structured, organized and
recognized program, such as Alcoholics Anonymous, Narcotics Anonymous, consisting of at least three original letters from
participants of the program. This form may be completed and submitted in lieu of a letter. Letters/forms must be signed and
dated within 45 days if appearing in person for a hearing. If being submitted as part of a Non-Resident Out-of-State Hearing
Application, the letters/forms must be signed and dated within 45 days of the postmark date. If additional space is needed, please
use the back of this form.
IMPORTANT: In addition to the minimum three letters, a petitioner must submit a personally prepared letter that
specifically identifies and explains what his/her support/recovery program consists of, who its members/participants
are, and how both the program and the fellow members/participants help him/her remain abstinent. The letter must
be in its original form, signed and dated within 45 days prior to being mailed to the Illinois Secretary of State’s office.
____________________________________________________
____________________________________________________
Petitioner’s Name (type or print)
Illinois Driver’s License Number
1.
What is your relationship to the petitioner (family member, friend, co-worker, etc.)?
2.
How long have you known the petitioner?
3.
How often do you see the petitioner (daily, weekly, monthly, etc.)?
4.
How are you involved in the petitioner’s support/recovery program, and how does that help the petitioner remain abstinent?
5.
If you knew the petitioner while he/she was actively drinking/using, what has changed that now enables you to help him/her
remain abstinent?
6.
What changes have you seen in the petitioner since he/she has been involved in this support/recovery program?
____________________________________________________
____________________________________________________
Signature
Date
__________________________________________________________________________________________________________
Address/City/State/ZIP
Printed by authority of the State of Illinois. April 2015 — 5M — DAH IH 67.4

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