Form 241
Petition for Immobilization/Forfeiture of Motor Vehicle
STATE OF VERMONT,
:DISTRICT COURT OF VERMONT
:UNIT [# ], [COUNTY] CIRCUIT
:DOCKET NO.
:[MONTH, DAY, YEAR]
PETITIONER
V
[YEAR, MAKE, MODEL]
VIN# ;
[DEFENDANT],
RESPONDENT
PETITION FOR
OF MOTOR VEHICLE
[IMMOBILIZATION/FORFEITURE]
NOW COMES the State of Vermont by and through
State's Attorney for County and petitions this Court to order the above-
described motor vehicle pursuant to sections [1213a/1213b/674(h)] and 1213c of
Title 23 of the Vermont Statutes Annotated.
In support thereof petitioner offers the following:
Respondent, , was charged with , offense on
1 .
Docket #
Respondent, , was driving above-described vehicle at the time of said
2.
offense.
was convicted of
3.
4.
If convicted of said
pursuant to 23 V.S.A. 1213a, et seq11213b1674(h) and 1213c et seq.
The Certificate of Title of said vehicle on file at the Department of Motor Vehicles,
5.
show HOLDER(S) of a lien on the vehicle. (copy attached).
A copy of the Petition and Notice have been served upon the registered owner(s), lienholder(s), and any
6.
party who has notified the State of an interest in the vehicle, all in compliance with the requirements of 23
V.S.A. § 1213c. (copy attached).
WHEREFORE the petitioner requests a hearing and order of following hearing.
Dated at , County of , Vermont, this day of
Signed:
,
.
.
,
on
.
offense, the vehicle is subject to
,
.
12/02 SML
DOES
DOES NOT
