Fillable RMV - LE101 Report And Affidavit Of An Operating After Suspension Or Revocation Incident

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RMV - LE101 Report And Affidavit Of An Operating After Suspension Or Revocation Incident

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Report and Affidavit of an Operating After
Suspension/Revocation Incident
Registry of Motor Vehicles ● Driver Control Unit
P.O. Box 55896 ●
Boston, MA 02205-5896
1 LE101_0318
Download and save this fillable form. Type to complete all highlighted fields on the form and save the file. Email that file,
along with any supporting documentation, to DCUOperatingAfterSuspension@massmail.state.ma.us
Documentation may also be printed and submitted to the Driver Control Uni
via FAX (857-368-0014) or US Mail to the address above.
A. Incident Information
Date of Request (MM/DD/YYYY)
Date of Incident (MM/DD/YYYY)
Incident Location
City
State
Citation #
Be advised that the person named below was cited for operating the vehicle referenced below after the
suspension/revocation of his/her license or right to operate. (M.G.L. c.90, s.23)
B. Operator Information
Name of Operator
Address
Street Address
City
Zip Code
Date of Birth (MM/DD/YYYY)
Exp. Date of License (MM/DD/YYYY)
License #
Issuing State
C. Vehicle Information
Vehicle Owner(s), If Different
Address
Street Address
City
Zip Code
Registration #
State
Exp. Date of Registration (MM/DD/YYYY)
Was the subject arrested?
Yes
No Were license plates/registration confiscated?
Yes
No
Signed under the penalties of perjury this _________________ day of ________________________ , _______________
Printed Name as Electronic Signature for Police Chief/Authorized Person: ______________________________________
Printed Name as Electronic Signature for Police Officer: ____________________________________________________
Police Department: __________________________________________________________________________________
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RMV - LE101 Report And Affidavit Of An Operating After Suspension Or Revocation Incident

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Completed 12 May 2020

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