Form PS31122 "Request for Administrative Review" - Minnesota

What Is Form PS31122?

This is a legal form that was released by the Minnesota Department of Public Safety - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2013;
  • The latest edition provided by the Minnesota Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PS31122 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS31122 "Request for Administrative Review" - Minnesota

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Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
R e que s t for Adm inis t r a tive Re view
Bring or mail this completed application to Driver and Vehicle Services, 445 Minnesota Street, St. Paul,
Minnesota 55101-5170. You may also fax to (651) 282-2463. Please print or type. Use additional sheets or attach
documents if necessary.
• If your driving privilege has been revoked or disqualified under the Implied Consent Law (Minnesota Statutes, sections
169A.50 -.53), you are entitled to a review of the order by the Commissioner of Public Safety.
Completing this form is the only means to advise the Commissioner of your version of the facts of the incident. It is
important that you complete each item and sign this form so that your request for administrative review is fully
considered.
Once received, the commissioner’s designee will undertake a full review of the facts surrounding the order of revocation
or disqualification, based upon this form and all other records in possession of the Department of Public Safety relating
to this incident.
This review will not affect pending or future court actions. All of your rights to seek court review of the revocation or
disqualification are preserved, whether or not you request administrative review.
You will be notified by mail of the results of the review within fifteen (15) days after receipt. You may appear in person
during normal business hours to discuss any driver’s license matter with a driver evaluator. In some cases, however, this
could result in a delay beyond the fifteen days within which a written review can be completed.
You may call (651) 296-8599 for information.
Date of Incident
(mm/dd/yy)
1. A peace officer must be able to state a reason for stopping a motor vehicle. In this case:
I agree that I was stopped for a valid reason.
I was not stopped for a valid reason because:
I don’t remember being stopped.
2. A peace officer must have probable cause to believe that a person was under the influence of alcohol or a
controlled substance while driving, operating or in physical control of a motor vehicle before a request for an
alcohol/controlled substance test of the driver’s blood, breath, or urine can be made.
I agree that the peace officer had probable cause to believe that I was under the influence of alcohol or a controlled
substance.
I do not think that the peace officer had probable cause to believe that I was under the influence because:
3. Before being requested to submit to an alcohol/controlled substance test of the driver’s blood, breath, or urine, a
driver is advised by the peace officer of certain rights and facts. These rights are usually read from a printed form.
The peace officer read the form and advised me of my rights and responsibilities.
I don’t recall whether or not I was given the required advice.
The peace officer failed to advise me as follows:
- over -
PS31122-09 (07/13)
Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
R e que s t for Adm inis t r a tive Re view
Bring or mail this completed application to Driver and Vehicle Services, 445 Minnesota Street, St. Paul,
Minnesota 55101-5170. You may also fax to (651) 282-2463. Please print or type. Use additional sheets or attach
documents if necessary.
• If your driving privilege has been revoked or disqualified under the Implied Consent Law (Minnesota Statutes, sections
169A.50 -.53), you are entitled to a review of the order by the Commissioner of Public Safety.
Completing this form is the only means to advise the Commissioner of your version of the facts of the incident. It is
important that you complete each item and sign this form so that your request for administrative review is fully
considered.
Once received, the commissioner’s designee will undertake a full review of the facts surrounding the order of revocation
or disqualification, based upon this form and all other records in possession of the Department of Public Safety relating
to this incident.
This review will not affect pending or future court actions. All of your rights to seek court review of the revocation or
disqualification are preserved, whether or not you request administrative review.
You will be notified by mail of the results of the review within fifteen (15) days after receipt. You may appear in person
during normal business hours to discuss any driver’s license matter with a driver evaluator. In some cases, however, this
could result in a delay beyond the fifteen days within which a written review can be completed.
You may call (651) 296-8599 for information.
Date of Incident
(mm/dd/yy)
1. A peace officer must be able to state a reason for stopping a motor vehicle. In this case:
I agree that I was stopped for a valid reason.
I was not stopped for a valid reason because:
I don’t remember being stopped.
2. A peace officer must have probable cause to believe that a person was under the influence of alcohol or a
controlled substance while driving, operating or in physical control of a motor vehicle before a request for an
alcohol/controlled substance test of the driver’s blood, breath, or urine can be made.
I agree that the peace officer had probable cause to believe that I was under the influence of alcohol or a controlled
substance.
I do not think that the peace officer had probable cause to believe that I was under the influence because:
3. Before being requested to submit to an alcohol/controlled substance test of the driver’s blood, breath, or urine, a
driver is advised by the peace officer of certain rights and facts. These rights are usually read from a printed form.
The peace officer read the form and advised me of my rights and responsibilities.
I don’t recall whether or not I was given the required advice.
The peace officer failed to advise me as follows:
- over -
PS31122-09 (07/13)
4. Before being offered an alcohol/controlled substance test, a driver must have:
a) been lawfully arrested,
b) been involved in an accident involving property damage or personal injury,
c) failed a preliminary breath test, or
d) refused to take a preliminary breath test.
In this case:
At least one of the four requirements listed above occurred.
None of the four requirements listed above occurred. Explain:
5. In some cases, it is reasonable to refuse to submit to an alcohol/controlled substance test. If you believe your
refusal to submit to testing was reasonable, what was your reason for refusing?
Not applicable because I took the test.
6. If an alcohol/controlled substance test was taken, it must be shown that the test was reliable and the results
properly evaluated. In this case:
I agree that the test was reliable and properly evaluated.
I don’t know if the test was reliable or properly evaluated.
The test was not reliable or not properly evaluated because:
7. In addition to the foregoing, I believe that the order of revocation or disqualification of my driving privilege is
improper because:
All information supplied on this form is public data, which, by Minnesota law, may be given to any person upon
request, and may be used for any lawful purposes. You are advised that information given in this form may be
used in any related court action involving your driver’s license, including any criminal charges that may result
from this incident.
Signature (driver must sign)
Date
(mm/dd/yy)
Subscribed and sworn to before me
First Name
Last Name
This ____________________ day
Of ______________ , 20______
DL Number (
)
OMIT DASHES
___________________________
NOTARY PUBLIC
Phone Number (
)
Date of Birth
TYPE NO DASHES OR SPACES
(mm/dd/yy)
PS31122-09 (07/13)
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