Fillable SOS257 258 Request For Hearing 432399 7 (Michigan)

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SOS257 258 Request For Hearing 432399 7 (Michigan)

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  • 16 check-boxes
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SOS-257/258 (1/27/20) Page 1 of 10
REQUEST FOR HEARING
Your appeal will be heard and decided by an attorney-hearing officer who will either appear in person or on screen via video
conferencing equipment. Once a hearing has been scheduled, you will be notified of the date, time and location. After the hearing, a
written decision will be available electronically or mailed to you based on your stated preference.
Your rights:
• You may bring an attorney with you; however, an attorney is not required.
• You may purchase a transcript of the hearing.
• If you disagree with the hearing decision, you can appeal the decision to a Michigan circuit court.
Documents required by the Michigan Department of State
a) Request for Hearing (SOS-257)
b) Substance Use Evaluation (SOS-258): If you have ever been arrested for an alcohol or controlled-substance related offense, you
must submit this form. The form must be completed, signed and dated within the last 90 days or it cannot be accepted.
c) If this hearing is the result of an alcohol or controlled-substance related driving offense:
• A laboratory report from a 12-Panel Urinalysis Drug Screen – This report must include at least two integrity variables
such as specific gravity, urine creatinine or pH level.
• Documentation of sobriety – Your sobriety must be confirmed by friends, family and co-workers, who are in a position to
know, observe and personally attest to your habits regarding the use of alcohol or controlled substances. You must either
submit three to six notarized testimonial letters with this form or bring three to six witnesses to your hearing who will testify
as to your sobriety. Letters must be signed, dated and notarized with a complete mailing address and telephone number where
the writer can be reached between 8 a.m. – 5 p.m. Eastern time. Letters must contain the following information about you:
1. The person’s relationship to you.
2. How often the person sees you.
3. How long the person has known you.
4. The last time the person saw or had knowledge of you drinking or using controlled substances.
5. The amount of alcohol or controlled substance the person knows you consumed on the last occasion.
6. What social activities you participate in involving alcohol or controlled substances.
7. The person’s knowledge of your past or current involvement in treatment or a support group.
• Evidence of support (as applicable) – Alcoholics Anonymous (AA) sign-in sheets, letters or other evidence that shows you
are attending a structured support group. If you have a sponsor, you should also include a notarized letter from that person.
• An ignition interlock report – If you have a restricted driver’s license and are required to use an ignition interlock device,
you must submit a report from the interlock vendor if you are requesting removal of the device. The report must state that the
ignition interlock device has been properly installed for at least the minimum time required by law and indicate whether any
alcohol readings or other violations have registered. The report must be an original with a raised seal that is no more than 30
days old when it is submitted with your hearing request. If you are using DAIS to request a hearing please submit proof from
the interlock vendor that you have requested an electronic copy of the report be delivered directly to AHS. If you are
appealing an ignition interlock violation, a full interlock report is not required.
d) Additional evidence – If you have ever attended a driver’s license appeal hearing, please refer to your last hearing order for any
additional information you may be required to submit. You may also submit any other evidence you believe is relevant to your
case.
SOS-257/258 (1/27/20) Page 2 of 10
REQUEST FOR AN ADMINISTRATIVE REVIEW
You may have the option to choose an administrative review in place of a hearing. You are eligible for an administrative review IF
ALL OF THE FOLLOWING APPLY:
• You are NOT a Michigan resident, and
• You are attempting to clear your Michigan driving record, and
• The licensing action you are appealing does not involve a fatality.
You will not have to appear in person for an administrative review. Instead, the Department of State will review the documents you
submit and its own records to determine if your full driving privileges can be reinstated. You will receive a decision by mail or
electronically. If the decision is unfavorable, you can still request an in-person or video hearing. You may only request one
administrative review in any 12-month period. Please place a check mark next to the statement below if you would like an
administrative review instead of a hearing.
___I am requesting an administrative review. I understand that the administrative review will be based on the written proofs that I
submit along with this form, and that the department may or may not accept additional evidence. I understand that previous license
appeal orders may be considered in making a decision. I also understand the administrative review will not be recorded and that no
testimony will be taken. I further understand the decision will be mailed or made available electronically after the administrative
review has been completed. Selecting this option does not affect my eligibility for a hearing.
Please fill out the information below. Whether you are applying for a hearing or an administrative review, this information
will assist the department in determining whether to restore your driving privileges. Submitting it does not guarantee you will
be approved for a driver’s license or a license clearance.
SECTION 1 – CONTACT INFORMATION
A. Your Contact Information (Please print or write clearly)
1. Full Name (From driver’s license or state ID card):
2. Address: Street, City, State, ZIP Code:
3. Date of Birth:
4. Michigan Driver’s License/State ID Card Number:
5. Telephone Number (8 a.m. – 5 p.m. Eastern time):
6. Email:
By selecting the box, I am opting in for all notifications for this case to be sent to me electronically, and I will
not receive any communication via US Mail. I understand I must set up an account through
https://milogin.michigan.gov to receive the notifications.
B. Your Attorney’s Contact Information (If an attorney is retained)
1. Attorney’s Name:
2. Attorney’s Bar Number:
3. Attorney’s Address: Street, City, State, ZIP Code:
4. Attorney’s Telephone Number:
5. Attorney’s Fax Number:
6. **Email:
7. **Attorney’s Signature:
By selecting the box, I am opting in for all notifications for this case to be sent to me electronically, and I will
not receive any communication via US Mail. Attorney’s signature is required to opt-in for electronic notifications.
An account must be set up through https://milogin.michigan.gov
CLEAR FORM
SOS-257/258 (1/27/20) Page 3 of 10
SECTION 2 – BACKGROUND INFORMATION
A. If you are a Michigan Resident:
1. How long have you lived in Michigan?
2. Where did you live before moving to Michigan?
B. If you are NOT a Michigan Resident:
1. Why did you leave Michigan?
2. When did you leave Michigan?
3. In which state or country are you currently living? (You must provide proof of your out-of-state residency. Please attach a copy
of your utility bill, lease or bank statement with this form.)
4. When did you become a permanent resident of your current state or country?
5. Why are you applying for clearance of your Michigan license?
6. Do you intend to re-establish residency in Michigan?
(Select “Yes” or “No”) YES _____ NO _____
7. If “Yes,” when will you establish Michigan residency?
SECTION 3 – CONVICTION HISTORY
Additional Information: Please attach all out-of-state driving records if applicable.
1. Have you ever been issued a driver’s license in another state? (Select “Yes” or “No”) YES _____ NO _____
If “Yes,” please list the state or states and the driver’s license numbers.
State
Driver’s License Number
2. Have you ever been involved in a crash in which someone was injured or killed when you were driving the vehicle?
(Select “Yes” or “No”) YES _____ NO _____
If “Yes,” please list the crash date and number of people injured or killed.
Crash Date
Number of Injuries
Number of Deaths
3. Do you currently have a case pending against you in any state for any driving or nondriving offense?
(Select “Yes” or “No”) YES _____ NO _____
If “Yes,” please list the offense, location and the court date.
Offense
Location
Court Date
SOS-257/258 (1/27/20) Page 4 of 10
4. Please list the last time you were convicted of a driving or nondriving civil infraction, misdemeanor or felony.
Conviction
Location
Date
SECTION 4 – SUBSTANCE USE HISTORY
1. Please list the convictions for an alcohol or controlled substance-related driving offense, such as drunken or impaired driving,
that you received in Michigan or in another state.
Driving Conviction
Date
Bodily Alcohol Content or Drug Type
(If known)
3. Have you ever been incarcerated, on probation or on parole for one or more alcohol or controlled substance-related offenses,
either as a driving or nondriving offense? (Select “Yes” or “No”) YES _____ NO _____
If “Yes,” please list the offense, location and date of the offense, and the release date.
Offense
Location
Date
Release Date
4. Describe your past drinking habits and controlled substance (including marijuana) use in detail.
Alcohol – What Kind of Alcohol
How Often
Amount Used
Controlled Substances – Type of Drug
(including marijuana)
How Often
Amount Used
5. Describe your current drinking habits and controlled substance (including marijuana) use in detail.
Alcohol – What Kind of Alcohol
How Often
Amount Used
2. Have you ever been convicted of any alcohol or controlled substance-related offenses that did not involve driving, such as
domestic violence, disorderly conduct, etc.? (Select “Yes” or “No”) YES _____ NO _____
If “Yes,” please list the conviction, date and BAC or drug type.
Nondriving Conviction
Date
Bodily Alcohol Content or Drug Type
(If known)
SOS-257/258 (1/27/20) Page 5 of 10
Controlled Substances – Type of Drug
(including marijuana)
How Often
Amount Used
6. Last time you consumed alcohol.
6a. Name of alcohol consumed.
6b. Amount consumed.
7. Last time you used a controlled
substance. (including marijuana)
7a. Name of controlled substance.
7b. Amount used.
8. Last time you drank a nonalcoholic
beer (Sharp’s, O’Doul’s, etc.).
8a. Name of nonalcoholic beer.
8b. Amount consumed.
9. Please explain your intentions regarding your future use of alcohol or controlled substances. (including marijuana)
10. Does your substance use evaluation accurately describe your use of alcohol or controlled substances (including marijuana),
past and present? (Select “Yes” or “No”) YES _____ NO ______
If “No,” please explain why not.
11. Are you currently taking any prescription medications? (Select “Yes” or “No”) YES _____ NO _____
If “Yes,” please list the drugs, the medical conditions associated with them, and how long you have been taking the medication.
Note: A physician’s Statement of Examination (DI4P) may be required.
Name of Drug
Medical Condition
Medication Use: Start Date - End Date
SECTION 5 – TREATMENT HISTORY
1. Have you ever joined or successfully completed a substance abuse, counseling or treatment program?
(Select “Yes” or “No”) YES _____ NO ______
If “Yes,” please list the program, date, location, attendance rate and treatment outcome. Attach verification of your completion.
Program Type
(Detoxification, Residential/In-patient,
Intensive Outpatient, Outpatient (Individual
or Group), Education, Driver Safety
Intervention Course)
Date Started
Date Ended
Name of Program, Therapist,
Group Leader and Location
Treatment Outcome
SOS-257/258 (1/27/20) Page 6 of 10
2. Have you ever participated in a medication-assisted treatment program (Methadone, Antabuse, Buprenorphine or Campral)?
(Select “Yes” or “No”) YES _____ NO ______
If “Yes,” please list the medication and the treatment dates.
Medication
Date Started
Date Ended
3. Have you ever tried abstinence as a means of controlling your alcohol or controlled substance (including marijuana) use?
(Select “Yes” or “No”) YES _____ NO _____
If “Yes,” please list when and for how long you maintained complete and total abstinence.
From
To
4. Have you ever abstained from alcohol or controlled substances (including marijuana) while incarcerated, on probation or on
parole?
(Select “Yes” or “No”) YES _____ NO ______
If “Yes,” please list when and for how long you maintained complete and total abstinence.
From
To
5. Have you ever used alcohol or controlled substances (including marijuana) after attempting to abstain from them?
(Select “Yes” or “No”) YES _____ NO ______
If “Yes,” please list when and for how long you maintained complete and total abstinence.
From
To
SECTION 6 – CONTINUUM OF CARE
1. Please list your participation in any lifetime support groups. Include the program name, dates attended, location, frequency of
attendance, sponsor’s name and any other relevant information.
Program Name
Start/End Dates
Location
Attendance
Sponsor
Other Information
SOS-257/258 (1/27/20) Page 7 of 10
2. Are you currently attending a community-based or 12-step support program?
(Select “Yes” or “No”) YES _____ NO ______
If “Yes,” please list the program name, dates attended, frequency of attendance, sponsor’s name and any other relevant
information.
Program Name
Start/End Dates
Location
Attendance
Sponsor
Other Information
3. Are you currently involved in any other recognized recovery program?
(Select “Yes” or “No”) YES _____ NO _____
If “Yes,” please list the program name, dates attended, frequency of attendance, sponsor’s name and any other relevant
information.
Program Name
Start/End Dates
Location
Attendance
Sponsor
Other Information
SECTION 7 – ADDITIONAL INFORMATION
For your hearing request or administrative review request: Please refer to your last hearing order for any additional information
you may be required to submit. You may also submit any other evidence you believe is relevant to your case. Attach any additional
pages as necessary.
SECTION 8 – FOREIGN LANGUAGE AND SIGN LANGUAGE INTERPRETERS
Foreign Language Interpreter: If you require a foreign language interpreter, it is your responsibility to make arrangements to have
one present at your hearing or review. The interpreter must be qualified by the state of Michigan and cannot be a family member or a
friend. If you need assistance in locating a foreign language interpreter, please contact the Department of State at 888-SOS-MICH
(767-6424).
Sign Language Interpreter: If you require a sign language interpreter, we will assist you in making the arrangements for an
interpreter. Please contact the Department of State at 888-SOS-MICH (767-6424) by calling the Michigan Relay Center at 800-649-
3777.
_____ I will need a SIGN LANGUAGE INTERPRETER (please check if it applies).
SECTION 9 – HEARINGS, VIDEO HEARINGS AND EVIDENCE AFFIDAVIT
You must attend your hearing in person.
Only hearings held in Grand Rapids, Lansing and Livonia are held face-to-face with a hearing officer. All other locations are video-
conferencing sites and you will not have an opportunity to hand anything to your hearing officer. Therefore, ALL evidence and
documentation must be submitted IN ADVANCE of your hearing, no matter whether your hearing officer will be in-person or on
the monitor.
Your submitted documentation must include:
SOS-257/258 (1/27/20) Page 8 of 10
a) The completed Request for Hearing form (SOS-257). Don’t forget to sign and date the Evidence Affidavit.
b) If you have ever been arrested for an alcohol or controlled substance related offense: Substance Use Evaluation (SOS-258).
The form must be completed, signed and dated within the last 90 days or it cannot be accepted.
c) If this hearing is the result of an alcohol or controlled substance-related driving offense:
1. A laboratory report from a 12-Panel Urinalysis Drug Screen.
2. Documentation of sobriety. (Submit three to six notarized testimonial letters with this form or bring three to six
witnesses to your hearing who will testify as to your sobriety.)
3. Evidence of support. If you have a sponsor, you should also include a notarized letter from that person.
4. An ignition interlock report or proof from the interlock vendor that you have requested an electronic copy of the
report be delivered directly to AHS (if required).
d) Any additional evidence you believe is relevant to your case.
By signing and dating the Evidence Affidavit below, you are affirming that all evidence has been submitted and you are ready for the
hearing to be scheduled.
EVI
DENCE AFFIDAVIT:
I have submitted all my evidence (substance abuse evaluation, testimonial letters, and, if required, ignition interlock report, etc.) for
my hearing. I also understand that the Department of State or hearing officer may refuse to accept additional written evidence after I
submit this affidavit.
U
nder the penalty of perjury, I certify that I am the petitioner in this matter and that the statements set forth in this document are true
and correct to the best of my knowledge and belief.
Y
ou will receive a written notice informing you of the date and time about 10 days before the hearing.
___________________________ _________________
Signature of Petitioner Date
P
LEASE FORWARD THIS ENTIRE FORM AND ALL REQUIRED DOCUMENTATION TO:
M
ichigan Department of State
P.O. Box 30196
Lansing, MI 48909-7696
Phone: 888-SOS-MICH (767-6424)
Fax: 517-335-2190
OR
CRE
ATE AN ACCOUNT AND SUBMIT ONLINE AT:
https://milogin.michigan.gov
(for petitioners)
or
at https://milogintp.michigan.gov
(for attorneys, law enforcement, prosecutors and attorneys general)
T
his form is available on the Department of State website at www.michigan.gov/sos. Click on “Forms,” “Suspended, Revoked or
Denied Driver’s License” and “Request for Hearing (SOS-257).”
click to sign
signature
click to edit
SOS-257/258 (1/27/20) Page 9 of 10
SUBSTANCE USE EVALUATION – (ALCOHOL AND DRUGS)
Please keep copies of all documents (including this form) that you submit.
SECTION 1: GENERAL INFORMATION and HISTORY (to be completed by driver/applicant)
Please print or type. Attach additional pages where necessary.
Name (First, Middle, Last)
Date of Birth
Driver’s License Number
Street Address
Telephone Number 8 a.m. – 5 p.m.
City
State
ZIP
Lifetime Conviction History:
List all driving convictions (e.g., operating while intoxicated or impaired driving) and non-driving convictions (e.g.,
drug crimes, domestic violence, MIP, or disorderly persons) involving alcohol or controlled substances. Include juvenile dispositions.
Driving
Convictions
Date
Bodily Alcohol Content or
Drug Type
(If known)
Non-driving
Convictions
Date
Bodily Alcohol Content or
Drug Type
(If known)
I authorize the Evaluator named on Page 2 to furnish the information set forth on this form and to discuss the information with the Michigan Department of
State.
I understand this form may also be used as my written request for hearing. I certify that my responses contained in this document are true and accurate to
the best of my knowledge and belief.
Driver/Applicant’s
Signature___________________________________________________________Date______________
SECTION 2: HISTORY and EVALUATION (to be completed by evaluator)
Please print or type. Attach additional pages where necessary.
Lifetime Treatment History for Alcohol and/or Drug Use Disorders: Attach each treatment plan and discharge report.
Program Type
(e.g., Detoxification, Residential/Inpatient,
Intensive Outpatient, Outpatient [individual
and/or group], Education, Driver Safety
Intervention Course)
Beginning and
Ending Dates
Name of Program,
Therapist or Group Leader,
and Location
Treatment Outcome
Medication assisted treatment (e.g., Methadone, Antabuse, Buprenorphine, or Campral): Medication: _____________________________
Prescribing Physician: ______________________________
Date started: _______________
Date ended:______________
Lifetime Support Group History: List all time periods of attendance and frequency.
Period Frequency
Type
(e.g., AA/NA or Women For Sobriety)
Sponsor Yes or No?
Diagnostic Impression (DSM-IV or DSM-V ): Indicate all past and present alcohol, drug and mental health diagnoses.
Diagnoses:
Supporting facts for diagnostic impression:
Course specifiers (check all that apply):
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
Sustained Recovery
Non-Applicable
click to sign
signature
click to edit
SOS-257/258 (1/27/20) Page 10 of 10
Testing Instruments: Attach the actual instrument used.
Testing Instruments Used
(e.g., ASI, SASSI-3, MAST/DAST)
Score Interpretation of results
Explain how the results of this test correlate
with the DSM-IV or DSM-V diagnosis on Page 1
Test 1:
Test 2:
Drug Screen:
Administer a 12-panel urinalysis drug screen (or refer client) and submit a current laboratory report that includes at least two urine
integrity variables. Please include the confirmation test for any positive screen results.
Comments:
If you administered an ethyl-glucoronide alcohol test, what were the results?
Lifetime Abstinence History:
Period of Abstinence
(Beginning and Ending Dates)
Abstinence Period Abated by What?
(Any abuse of prescription medication or use of
alcohol, controlled substance, or NA beer)
Comments
Client Prognosis:
Please check one: Poor Guarded Fair Good Excellent
Provide supporting facts for this prognosis (consider the client’s current living and work environments, lifestyle, relapse history,
use of addictive prescribed medications, and any other relevant factors that may affect the overall prognosis):
Date of last use of:
Alcohol and/or NA Beer: _________________
Controlled Substances:____________________
(Including illicit drugs and addictive prescription medications)
Continuum of Care Recommendations:
Please check all that apply:
Professional Treatment
Educational
Course
Community Support Group
(e.g., AA/NA, Women for
Sobriety, SMART Recovery)
Other _________________
None
Reasons for recommendation or if none, please state reasons:
Certification of Evaluator:
As of this date, I certify that I have reviewed Section 1 and completed Section 2 and that this Substance Use Evaluation is true to the best of my knowledge and
belief based on information obtained from the client, the client’s known substance use disorder and mental health history, and a client examination. I
understand that the decision to grant, suspend, or reinstate an individual’s driving privileges rests solely with the Department of State, which may consider other
facts or conditions when making this decision.
Evaluator’s Name (printed or typed)
Qualifications/Degrees
Date
Evaluator’s Signature
Telephone Number
Program Name
Program License Number
Address
City
State
ZIP
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SOS257 258 Request For Hearing 432399 7 (Michigan)

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Completed 29 June 2021

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