Form CIV 111 Petition for Court Hearing on Reinstatement of Driver's License - Minnesota

Form CIV111 or the "Petition For Court Hearing On Reinstatement Of Driver's License" is a form issued by the Minnesota District Courts.

The form was last revised in July 1, 2015 and is available for digital filing. Download an up-to-date Form CIV111 in PDF-format down below or look it up on the Minnesota District Courts Forms website.

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State of Minnesota
District Court
County
Judicial District:
Court File Number:
Case Type:
Other Civil
______________________________,
Petitioner
vs.
Petition for Hearing on
Reinstatement of Driver’s License
Minn. Stat. § 171.19
Commissioner of Public Safety,
Respondent
Petitioner petitions this Court for reinstatement of his/her driving privileges pursuant to Minn.
Stat. §171.19 and states as follows:
1.
My name is
and I currently live at
(address) in
(County).
2.
On or about _____________________ (date), I received notice from the Department of
Public Safety, Driver and Vehicle Services Division, that stated my driver’s license will
be or was (check the box that applies)
refused
suspended
revoked
cancelled
disqualified, effective
(date), for a period of __________(days/year).
3.
The notice states that my license was taken because
and that the incident occurred in (name of city)
My license was not revoked or disqualified under Minn. Stat. § 169A.52 for failing or
4.
refusing a chemical test to determine intoxication, and was not suspended for non-
payment of support under Minn. Stat. § 171.186.
5.
For the license problem described at #2 and #3:
This is the first time I have filed a court Petition for reinstatement of my driving
license OR
CIV111
State
ENG
Rev 7/15
www.mncourts.gov/forms
Page 1 of 2
State of Minnesota
District Court
County
Judicial District:
Court File Number:
Case Type:
Other Civil
______________________________,
Petitioner
vs.
Petition for Hearing on
Reinstatement of Driver’s License
Minn. Stat. § 171.19
Commissioner of Public Safety,
Respondent
Petitioner petitions this Court for reinstatement of his/her driving privileges pursuant to Minn.
Stat. §171.19 and states as follows:
1.
My name is
and I currently live at
(address) in
(County).
2.
On or about _____________________ (date), I received notice from the Department of
Public Safety, Driver and Vehicle Services Division, that stated my driver’s license will
be or was (check the box that applies)
refused
suspended
revoked
cancelled
disqualified, effective
(date), for a period of __________(days/year).
3.
The notice states that my license was taken because
and that the incident occurred in (name of city)
My license was not revoked or disqualified under Minn. Stat. § 169A.52 for failing or
4.
refusing a chemical test to determine intoxication, and was not suspended for non-
payment of support under Minn. Stat. § 171.186.
5.
For the license problem described at #2 and #3:
This is the first time I have filed a court Petition for reinstatement of my driving
license OR
CIV111
State
ENG
Rev 7/15
www.mncourts.gov/forms
Page 1 of 2
I previously filed a Petition and the court denied my request to get my driver’s license
reinstated. The hearing date was
______________and today is at least 1 year
(mo/day/yr)
since the hearing date.
(If it is less than one year, you cannot file now.)
6.
My date of birth is _____________________________________.
My driver’s license number is ____________________________________.
7.
8.
I believe that my license should be reinstated because
9.
I am filing this petition within 180 days of the effective date of the order of
revocation, suspension, cancellation, disqualification or refusal notice.
I am filing this petition before the expiration date of the revocation, suspension,
cancellation, disqualification or refusal.
Wherefore, petitioner seeks judgment of this Court as follows:
1. Reinstatement of petitioner’s driving privileges pursuant to Minn. Stat. §171.19.
2. For such other and further relief as the Court deems just and proper.
Dated:
Signature of Petitioner, Self-Represented Litigant
Name:
Address
City/State/Zip:
Telephone: (
)
E-mail address:
CIV111
State
ENG
Rev 7/15
www.mncourts.gov/forms
Page 2 of 2

Download Form CIV 111 Petition for Court Hearing on Reinstatement of Driver's License - Minnesota

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