Form DAH IH 71 Documentation of Non-traditional Support/Recovery Program Cover Letter - Illinois

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Office of the
DOCUMENTATION OF NON-TRADITIONAL
Secretary of State
SUPPORT/RECOVERY PROGRAM
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
COVER LETTER
Additional forms may be obtained at
www.cyberdriveillinois.com
If your support/recovery program does not involve a structured, organized and recognized program, such as Alcoholics
Anonymous or Narcotics Anonymous, you must document the program by submitting an original, personally prepared letter,
signed and dated by you, which includes the following information. This form may be completed and submitted in lieu of the
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.
____________________________________________________
____________________________________________________
Petitioner’s Name (type or print)
Illinois Driver’s License Number
1.
Describe the type of program you are involved in that helps you remain abstinent from using alcohol/drugs:
2.
List the names of those who are involved in the program and their relationship to you (family members, friends, church
members, co-workers, etc.):
3.
Explain specifically what these support members do to help you remain abstinent from alcohol/drugs:
4.
Explain how the program works and keeps you abstinent from alcohol/drugs:
____________________________________________________
____________________________________________________
Signature
Date
__________________________________________________________________________________________________________
Address/City/State/ZIP
Printed by authority of the State of Illinois. April 2015 — 2M — DAH IH 71.1
Print
Reset
Save
Office of the
DOCUMENTATION OF NON-TRADITIONAL
Secretary of State
SUPPORT/RECOVERY PROGRAM
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
COVER LETTER
Additional forms may be obtained at
www.cyberdriveillinois.com
If your support/recovery program does not involve a structured, organized and recognized program, such as Alcoholics
Anonymous or Narcotics Anonymous, you must document the program by submitting an original, personally prepared letter,
signed and dated by you, which includes the following information. This form may be completed and submitted in lieu of the
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.
____________________________________________________
____________________________________________________
Petitioner’s Name (type or print)
Illinois Driver’s License Number
1.
Describe the type of program you are involved in that helps you remain abstinent from using alcohol/drugs:
2.
List the names of those who are involved in the program and their relationship to you (family members, friends, church
members, co-workers, etc.):
3.
Explain specifically what these support members do to help you remain abstinent from alcohol/drugs:
4.
Explain how the program works and keeps you abstinent from alcohol/drugs:
____________________________________________________
____________________________________________________
Signature
Date
__________________________________________________________________________________________________________
Address/City/State/ZIP
Printed by authority of the State of Illinois. April 2015 — 2M — DAH IH 71.1

Download Form DAH IH 71 Documentation of Non-traditional Support/Recovery Program Cover Letter - Illinois

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