Form AOC-CVR-12 "Affidavit and Revocation Report of Law Enforcement Officer for Provisional License Revocation" - North Carolina

What Is Form AOC-CVR-12?

This is a legal form that was released by the North Carolina District Court - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2012;
  • The latest edition provided by the North Carolina District Court;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AOC-CVR-12 by clicking the link below or browse more documents and templates provided by the North Carolina District Court.

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Download Form AOC-CVR-12 "Affidavit and Revocation Report of Law Enforcement Officer for Provisional License Revocation" - North Carolina

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File No.
STATE OF NORTH CAROLINA
County
In The General Court Of Justice
District Court Division
IN THE MATTER OF
Name
AFFIDAVIT AND REVOCATION REPORT
OF LAW ENFORCEMENT OFFICER
Address
FOR PROVISIONAL LICENSE REVOCATION
City
State
Zip
G.S. 20-13.3
Race
Sex
Date of Birth
Drivers License No.
State
Vehicle Type
CMV
Haz. Mat.
Citation No.
The undersigned being first duly sworn says:
1. I am a law enforcement officer. On the
day of
,
, at
(a.)(p.)m, a law enforcement officer had reasonable grounds to believe the above named person, hereinafter referred
to as driver, operated a vehicle (
commercial motor vehicle) in the above named county upon
(give street, highway, or
while committing a criminal moving
public vehicular area)
violation as defined in G.S. 20-13.3(a)(2), in that
(list sufficient facts to establish probable cause)
.
2. A law enforcement officer charged the driver with the criminal moving violation of
(give statute for offense)
.
3. The driver is a provisional licensee under age 18 as defined in G.S. 20-13.3(a)(4).
4. The driver is not subject to a civil revocation pursuant to G.S. 20-16.5.
5. If the criminal moving violation is one for which no initial appearance is required, a law enforcement officer verbally
notified the driver that the driver’s permit or license is subject to revocation pursuant to G.S. 20-13.3, and a law
enforcement officer provided the driver with form AOC-CVR-15 containing notice of the process for revocation and
hearing under G.S. 20-13.3.
Signature Of Law Enforcement Officer
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date
Signature Of Official Authorized To Administer Oaths
Print Name Of Law Enforcement Officer
Agency Name
Magistrate
Deputy CSC
Assistant CSC
CSC
Date My Commission Expires
County Where Notarized
Notary
SEAL
NOTE TO OFFICER: “If a provisional licensee's permit or license is subject to revocation under this section, the law
enforcement officer must execute a revocation report. It is the specific duty of the law enforcement
officer to make sure that the report is expeditiously filed with a judicial official as required by this
section . . . . The judicial official with whom the revocation report must be filed is: (1) The judicial
official conducting the initial appearance on the underlying criminal moving violation. [or] (2) The
clerk of superior court in the county in which the underlying criminal charge has been brought if no
initial appearance is required.” G.S. 20-13.3(c) & (c1).
Original - Magistrate/CVR File
AOC-CVR-12, Rev. 10/12
© 2012 Administrative Office of the Courts
File No.
STATE OF NORTH CAROLINA
County
In The General Court Of Justice
District Court Division
IN THE MATTER OF
Name
AFFIDAVIT AND REVOCATION REPORT
OF LAW ENFORCEMENT OFFICER
Address
FOR PROVISIONAL LICENSE REVOCATION
City
State
Zip
G.S. 20-13.3
Race
Sex
Date of Birth
Drivers License No.
State
Vehicle Type
CMV
Haz. Mat.
Citation No.
The undersigned being first duly sworn says:
1. I am a law enforcement officer. On the
day of
,
, at
(a.)(p.)m, a law enforcement officer had reasonable grounds to believe the above named person, hereinafter referred
to as driver, operated a vehicle (
commercial motor vehicle) in the above named county upon
(give street, highway, or
while committing a criminal moving
public vehicular area)
violation as defined in G.S. 20-13.3(a)(2), in that
(list sufficient facts to establish probable cause)
.
2. A law enforcement officer charged the driver with the criminal moving violation of
(give statute for offense)
.
3. The driver is a provisional licensee under age 18 as defined in G.S. 20-13.3(a)(4).
4. The driver is not subject to a civil revocation pursuant to G.S. 20-16.5.
5. If the criminal moving violation is one for which no initial appearance is required, a law enforcement officer verbally
notified the driver that the driver’s permit or license is subject to revocation pursuant to G.S. 20-13.3, and a law
enforcement officer provided the driver with form AOC-CVR-15 containing notice of the process for revocation and
hearing under G.S. 20-13.3.
Signature Of Law Enforcement Officer
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date
Signature Of Official Authorized To Administer Oaths
Print Name Of Law Enforcement Officer
Agency Name
Magistrate
Deputy CSC
Assistant CSC
CSC
Date My Commission Expires
County Where Notarized
Notary
SEAL
NOTE TO OFFICER: “If a provisional licensee's permit or license is subject to revocation under this section, the law
enforcement officer must execute a revocation report. It is the specific duty of the law enforcement
officer to make sure that the report is expeditiously filed with a judicial official as required by this
section . . . . The judicial official with whom the revocation report must be filed is: (1) The judicial
official conducting the initial appearance on the underlying criminal moving violation. [or] (2) The
clerk of superior court in the county in which the underlying criminal charge has been brought if no
initial appearance is required.” G.S. 20-13.3(c) & (c1).
Original - Magistrate/CVR File
AOC-CVR-12, Rev. 10/12
© 2012 Administrative Office of the Courts
“CRIMINAL MOVING VIOLATIONS”
UNDER G.S. 20-13.3
G.S. 20-137.4
Operating a school bus while using a mobile phone
G.S. 20-137.4A
Operating a school bus while using a mobile phone to text or access electronic mail
G.S. 20-138.1*
Driving while impaired
G.S. 20-138.2*
Driving while impaired in a commercial motor vehicle
G.S. 20-138.2A*
Operating a commercial motor vehicle after consuming alcohol
G.S. 20-138.2B*
Operating a school bus, school activity bus, or child care vehicle after consuming alcohol
G.S. 20-138.3*
Operating a motor vehicle by a person less than 21 years old while or after consuming alcohol or
drugs
G.S. 20-138.5*
Habitual impaired driving
G.S. 20-138.7(a)*
Operating a motor vehicle while there is an open container of alcohol in the passenger area and
while the driver is consuming or has consumed alcohol
20-140
Reckless driving
20-141(j1)
Speeding more than 15 MPH over limit or speeding over 80 MPH
20-141(j3)
Speeding in a commercial motor vehicle carrying a load that is subject to the permitting requirements of
G.S. 20-119 and (i) driving 15 MPH or more over the posted speed or (ii) driving 15 MPH or more over the
permit speed
20-141.3
Operating a motor vehicle willfully in a prearranged speed competition, or operating a motor vehicle willfully
in speed competition, or allowing one’s vehicle to be operated in a prearranged speed competition, or
wagering on a prearranged speed competition
20-141.4*
Death and injury by vehicle
20-141.5
Speeding to elude arrest
20-141.6
Aggressive driving
20-149(b)
Improper operation by an overtaken driver causing a collision resulting in serious bodily injury, bodily
injury, or property damage
20-157(a), (h), (i)
Failing to move over for law enforcement or emergency vehicle giving warning signal, or violating G.S. 20-
157 and causing damage to property or injury, or violating G.S. 20-157 and causing serious injury or death
20-166(a), (a1), (b), (c), (c1) Failing to stop and remain after a crash resulting in serious bodily injury or death, or failing to stop and
remain after a crash resulting in injury, or failing to provide information or render assistance following a
crash, or failing to stop and remain after a crash resulting in damage to property or non-apparent injury
20-166.1
Failing to notify law enforcement or other owner following crash, or failing to provide proof of insurance to
DMV upon request
20-166.2
Failing, when a passenger in a vehicle involved in a crash, to remain at the scene, or provide information,
or render assistance
20-167.1
Transporting spent nuclear fuel without notifying NCSHP in advance
NOTE: An offense indicated by * is an implied-consent offense that supports a CVR under G.S. 20-16.5.
AOC-CVR-12, Side Two, Rev. 10/12
© 2012 Administrative Office of the Courts
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