SECTION 1 – JUDGE’S NAME
By order of the Honorable	, the minor
(print)
listed on this form shall have his/her driving privilege to operate a motor vehicle in the State of South Carolina

restricted in the manner described below:

SECTION 2 - MINOR’S INFORMATION

Name:

Address:

City:

State:

Zip Code:

Credential Number:

Date of Birth:

Parent(s), Guardian or Custodian:

Address:

City:

State:

Zip Code:

SECTION 3 - RESTRICTION INFORMATION

SC Code of Law §16-17-500 (E)-(4) Tobacco Restriction- Minor

Effective Date of Restriction:

Termination Date of Restriction:

1. Driving privileges are restricted to driving to and from school.

2. Driving privileges are restricted to driving to and from work.

3. Driving privileges are restricted to driving to and from church.

4. Driving privileges are restricted, as the court considers appropriate (additional instructions below).

5. Minor is not licensed and the issuance of a driver’s license or beginner’s permit is delayed for 90 days after making application for a credential or until the minor’s 18th birthday.

Additional Instructions:

SECTION 4 – COURT INFORMATION

Date:

Judge’s Signature:

Court Name:

Court Address:

South Carolina Department of Motor Vehicles

Court Order Restriction of Driving Privileges

Tobacco Prevention Act - Minor

VS-200

(Est. 10/06)

Mail this completed form to: SC Department of Motor Vehicles, Driver Records, P.O. Box 1498, Blythewood, SC 29016-0028

Once this restriction is recorded, DMV will mail the original court order to the customer.

A copy of this court order will be kept on file at the DMV.

The customer is to keep this court order in his/her possession when driving during this restriction period.

South Carolina Department of Motor Vehicles

Fouty_PeggyD

2006-10-18

SCJD

South Carolina Division of Motor Vehicles