STATE OF SOUTH CAROLINA	)

)	IN THE COURT OF

GENERAL SESSIONS
)	Judicial Circuit
County of	)

STATE OF SOUTH CAROLINA	)

)

Petitioner	)
)	VEHICLE IMMOBILIZATION
Vs.	)
)
)	Case Number -GS- -
Defendant	)
Date of Birth

SCDL #	)

Pursuant to S.C. Code Ann. § 56-5-2942(J), you are required to surrender all license plates and vehicle registration numbers to the Department of Motor Vehicles so that all vehicles registered to or owned by you may be immobilized as a result of this conviction. Upon notification from the DMV, you must surrender the license plates from all vehicles listed below as required by law.

Please list the make and model of each vehicle registered in your name, the corresponding license plate number and vehicle registration number of each vehicle.

Vehicle Make and Model	License Plate Number	Registration Number

I hereby certify that the information I have provided is true, accurate, and complete under penalty of perjury in accordance with S.C. Code Ann. § 16-9-10.

_________________________________	_______________________________
Defendant	Date

SCCA / 220 (01/04)

STATE OF SOUTH CAROLINA

DSmith

2004-01-14

cyon

S.C. Judicial Dept.