Verification of Hearing Documents - Illinois

This "Verification of Hearing Documents" is a Illinois-specific form released by the Illinois Secretary of State on August 1, 2009.

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
VERIFICATION OF
Secretary of State
HEARING DOCUMENTS
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
Additional forms may be obtained at
www.cyberdriveillinois.com
A DUI service provider should use this form to verify that a document(s) is a true and correct copy (identical reproduction) of
the original, or to provide reasons why it is unable to provide the original of a document(s).
____________________________________________________
____________________________________________________
Client/Petitioner’s Name
Illinois Driver’s License Number
■ ■
1.
The following document(s) is a true and correct/identical copy of the original(s) as verified by the service provider
whose signature appears on the following page.
Check Appropriate Document(s):
Date of Document
■ ■
Alcohol/Drug Evaluation Uniform Report
________________________________
■ ■
Addendum to Uniform Report
________________________________
■ ■
DUI Risk Education Certificate of Completion
________________________________
■ ■
Discharge/Transfer Authorization and Treatment
Summary Including Individualized Treatment Plan
________________________________
■ ■
Secretary of State Treatment Verification Form
________________________________
■ ■
Secretary of State Alcohol/Drug Evaluation
Uniform Report Update(s)
________________________________
■ ■
Other (specify): ____________________________________
________________________________
■ ■
2.
The original of the following document(s) is no longer available for the following reason(s) as verified by the service
provider whose signature appears on the following page.
Check Appropriate Document(s):
Date of Document
■ ■
Alcohol/Drug Evaluation Uniform Report
________________________________
■ ■
Addendum to Uniform Report
________________________________
■ ■
DUI Risk Education Certificate of Completion
________________________________
■ ■
Discharge/Transfer Authorization and Treatment
Summary Including Individualized Treatment Plan
________________________________
■ ■
Secretary of State Treatment Verification Form
________________________________
■ ■
Secretary of State Alcohol/Drug Evaluation
Uniform Report Update(s)
________________________________
■ ■
Other (specify): ____________________________________
________________________________
Check Appropriate Reason:
■ ■
The document has been destroyed.
■ ■
The client informs this agency that he/she lost the original document.
■ ■
The agency that composed the document is no longer in operation and did not transfer its records to this agency
when it ceased operation.
■ ■
Other (explain):
____________________________________________________
____________________________________________________
Service Provider’s Name and Title (type or print)
Date
____________________________________________________
____________________________________________________
Service Provider’s Signature
Accreditation/License Number
Printed by authority of the State of Illinois. August 2009 — 1 — DAH H 82
Print
Reset
Save
Office of the
VERIFICATION OF
Secretary of State
HEARING DOCUMENTS
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
Additional forms may be obtained at
www.cyberdriveillinois.com
A DUI service provider should use this form to verify that a document(s) is a true and correct copy (identical reproduction) of
the original, or to provide reasons why it is unable to provide the original of a document(s).
____________________________________________________
____________________________________________________
Client/Petitioner’s Name
Illinois Driver’s License Number
■ ■
1.
The following document(s) is a true and correct/identical copy of the original(s) as verified by the service provider
whose signature appears on the following page.
Check Appropriate Document(s):
Date of Document
■ ■
Alcohol/Drug Evaluation Uniform Report
________________________________
■ ■
Addendum to Uniform Report
________________________________
■ ■
DUI Risk Education Certificate of Completion
________________________________
■ ■
Discharge/Transfer Authorization and Treatment
Summary Including Individualized Treatment Plan
________________________________
■ ■
Secretary of State Treatment Verification Form
________________________________
■ ■
Secretary of State Alcohol/Drug Evaluation
Uniform Report Update(s)
________________________________
■ ■
Other (specify): ____________________________________
________________________________
■ ■
2.
The original of the following document(s) is no longer available for the following reason(s) as verified by the service
provider whose signature appears on the following page.
Check Appropriate Document(s):
Date of Document
■ ■
Alcohol/Drug Evaluation Uniform Report
________________________________
■ ■
Addendum to Uniform Report
________________________________
■ ■
DUI Risk Education Certificate of Completion
________________________________
■ ■
Discharge/Transfer Authorization and Treatment
Summary Including Individualized Treatment Plan
________________________________
■ ■
Secretary of State Treatment Verification Form
________________________________
■ ■
Secretary of State Alcohol/Drug Evaluation
Uniform Report Update(s)
________________________________
■ ■
Other (specify): ____________________________________
________________________________
Check Appropriate Reason:
■ ■
The document has been destroyed.
■ ■
The client informs this agency that he/she lost the original document.
■ ■
The agency that composed the document is no longer in operation and did not transfer its records to this agency
when it ceased operation.
■ ■
Other (explain):
____________________________________________________
____________________________________________________
Service Provider’s Name and Title (type or print)
Date
____________________________________________________
____________________________________________________
Service Provider’s Signature
Accreditation/License Number
Printed by authority of the State of Illinois. August 2009 — 1 — DAH H 82

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