IN THE MAUMEE MUNICIPAL COURT

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                                                            Petitioner                       Case No. ____________________        

Re:  Case No(s). (if known):                                                                     PETITION TO ESTABLISH
____________________________                                       PAYMENT PLAN FOR
____________________________                                       REINSTATEMENT FEES OWED
____________________________                                       TO BUREAU OF MOTOR VEHICLES
                                                                    

            Now comes the Petitioner, _____________________________, and states that he/she resides
in the jurisdiction of the Maumee Municipal Court, and that he/she is an adult. 

            Petitioner further states that he/she owes reinstatement fee(s) to the Bureau of Motor Vehicles in
the sum of $_______________________ for which he/she is under suspension. 

            Petitioner further states that, pursuant to Section 4510.10(B) O.R.C., he/she would like to establish
a reasonable payment plan of not less than $50.00 per month, to be paid to the Bureau of Motor Vehicles in
all succeeding months (not to exceed 180 days) until all reinstatement fees required are paid in full. 

            Petitioner further states that he/she agrees to pay all costs of this proceeding. 

            Petitioner further states that he/she (but for the payment of the reinstatement fees) otherwise would
be entitled to operate a vehicle in this state or to obtain reinstatement of his/her operating privileges. 

            Petitioner requests that he/she be granted limited operating privileges in order to enable him/her to
reasonably acquire the delinquent reinstatement fees due and owing. 

            Wherefore, Petitioner prays that a reasonable payment plan of at least $50.00 per month be established
to be paid to the Bureau of Motor Vehicles in all succeeding months (not to exceed 180 days) until all reinstatement fees required are paid in full. 

                                                                                                                _________________________________
                                                                                    Petitioner/Petitioner's Attorney
                                                                                    Telephone No. ____________________  

Social Security Number:            ____________________________
Driver’s License Number:            ___________________________
Date of Birth:                            ____________________________