Event Code: 2973 Law 611 / Rev. 10-06-2015 1

IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA

CASE NUMBER: 05 - - DR - -XXXX-XX

OBLIGEE CLOCK IN _______________________________

OBLIGOR _______________________________

MOTION TO CONTEST DRIVER LICENSE SUSPENSION

Obligor date of birth: _______________________

Obligor Driver License #: _______________________

I, _______________________________, the obligor in the above referenced case, contest the delinquency action pursuant to 61.13016 F. S., on the ground of (check the box that applies)

mistake of fact regarding the amount of a delinquency mistake of fact regarding the identity of the obligor

The facts that support my motion are: (list the reason(s) why you contest the delinquency action) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I certify that a copy of this Motion to Contest Driver License Suspension was mailed to the obligee on _______________________ and a copy was served on the Clerk of Court on ___________________, 20___.

Dated this _______ day of _________________, 20___.

____________________________________ Obligor’s Signature ____________________________________ Address ____________________________________ check if address change Address