Fillable Printable Form AA-33A - Administrative Appeal Form - New York

Form AA-33A - Administrative Appeal Form - New York

YOU MUST COMPLETE PAGE 2 OF THIS FORM.

New York State Department of Motor Vehicles

ADMINISTRATIVE APPEAL FORM (AA-33A)

VEHICLE AND TRAFFIC LAW ARTICLES 3-A and 12-A

(THIS FORM IS NOT TO BE USED TO APPEAL TRAFFIC VIOLATION BUREAU TICKETS)

I REQUEST THAT THE FINE, SUSPENSION OR REVOCATION BE STAYED (STOPPED) PENDING THE OUTCOME OF THE APPEAL.

Stays pending appeals are granted in the discretion of the Board (except for most Article 12-A appeals). The Appeals Board will not grant a stay unless the

appeal fee is paid and valid reasons for the appeal and for needing the stay are provided on page 2 of this form. You will be notified whether your request

for a stay has been granted or denied.

If a hearing was held, the Appeals Board may review hearing testimony only if you order and pay for a transcript in a proper and timely manner. The Appeals

Board will acknowledge receipt of your appeal form and fee with a letter that will direct you to send a transcript deposit to the designated Transcription company

within 30 days of the date of the letter. The Appeals Board does not accept transcript payments

. If you do not receive an acknowledgment letter, contact the Appeals

Board at (518) 474-1052 or at the address above. The Appeals Board will not review hearing testimony unless all transcript payments are timely and complete.

IF A HEARING WAS HELD, check the appropriate box below:

You must send this COMPLETED, SIGNED APPEAL FORM (2 pages) and a $10 APPEAL FEE to the DMV Appeals Board. Read this entire form carefully.

Type or print all information clearly. You must state your reason for the appeal on page 2 of this form. You must pay a non-refundable

$10 appeal fee for

each CASE NUMBER you appeal

. DO NOT SEND CASH. Appeal fees must be paid by check or money order, payable to the “Commissioner of Motor

Vehicles.” Print your case number(s) on your check or money order. A $35 penalty is charged for dishonored checks.

You must send this

APPEAL FORM and the APPEAL FEE(S) to the DMV Appeals Board WITHIN SIXTY (60)

DAYS OF THE DATE OF THE DEPARTMENT’S ORDER OF SUSPENSION/REVOCATION, DECISION LETTER,

OR NOTICE

. If you file by mail, the USPS postmark will be used to determine if your appeal is timely. If the

postmark is illegible, the date your appeal is received by the Board will determine timeliness. You should keep

copies of your completed appeal form, appeal fee, and proof of mailing.

I WANT THE HEARING TESTIMONY REVIEWED BY THE BOARD. I UNDERSTAND THAT I AM REQUIRED TO PAY A TRANSCRIPT DEPOSIT TO THE

TRANSCRIPTION COMPANY WITHIN 30 DAYS OF THE DATE OF THE LETTER ACKNOWLEDGING RECEIPT OF THIS APPEAL.

I DO NOT WANT A TRANSCRIPT OF THE HEARING TO BE PRODUCED. I UNDERSTAND THAT THE BOARD WILL NOT REVIEW HEARING TESTIMONY.

DMV USE ONLY

Last Name

Date of Birth:

Corporate Name or DBA

Appeal Mailing Address (Street)

State Zip Code

City

State Zip Code

City

ATTORNEY FOR THIS APPEAL (if any)

Date of Each Hearing

Date of Decision/Order

Hearing Location(s)

Administrative Law Judge

Facility/Certificate Number

Case Number(s)

First Name M.I.

Type of Appeal (Chemical Test Refusal, License Denial, Inspection, Dealer, Repair Shop, etc.)

NYS Driver License

Client ID Number

Sex

o Male o Female

AA-33A (5/13)

Attorney Mailing Address (Street)

PAGE 1 OF 2

o $10 APPEAL FEE(S) RECEIVED o NO FEE RECEIVED

o CHECK o MONEY ORDER o AMOUNT: $ ______________

DMV

USE

ONLY

MM DD YYYY

DATE:

STAY:

REQUIRED APPEAL INFORMATION

HEARING TRANSCRIPTS

REQUESTING A STAY

WHERE TO SEND AN APPEAL

DEADLINE TO FILE AN APPEAL

WHAT IS REQUIRED TO FILE AN APPEAL

WHAT IS THE SUBJECT OF YOUR APPEAL (Check the appropriate box.)

All correspondence for this appeal will be sent to the address(es) supplied on this appeal form. You must notify the Appeals Board in writing immediately of

any change of address that occurs after this appeal is filed.

o CHEMICAL TEST REFUSAL– DMV HEARING HELD

o DENIAL OF APPLICATION FOR DRIVER LICENSE, CERTIFICATE OR PRIVILEGE – NO DMV HEARING HELD

o FACILITY LICENSE OR CERTIFICATE, including INSPECTION STATION, INSPECTOR, DEALER, REPAIR SHOP – DMV HEARING HELD

o FATAL ACCIDENT, PERSISTENT VIOLATOR, FALSE STATEMENT– DMV HEARING HELD

o ALL OTHERS – including OTHER DETERMINATIONS MADE WITHOUT A DMV HEARING

Mail the appeal form and

appeal fee(s) to:

DMV APPEALS BOARD

P.O. BOX 2935

ALBANY, NY 12220-0935

Sign Here ç _________________________________________________________________ Date________________________

AA-33A (5/13)

PAGE 2 OF 2

www.dmv.ny.gov

New York State Department of Motor Vehicles

ADMINISTRATIVE APPEAL FORM (AA-33A)

VEHICLE AND TRAFFIC LAW ARTICLES 3-A and 12-A

(THIS FORM IS NOT TO BE USED TO APPEAL TRAFFIC VIOLATION BUREAU TICKETS)

Any exhibits submitted at the hearing will become part of the appeal record. The Appeals Board reviews the entire record created at the hearing. The Board

will review a transcript of the hearing only if you order it and pay for it in a timely manner.

To receive copies of hearing exhibits for personal use, submit a

FREEDOM OF INFORMATION LAW (FOIL) request to: DMV FOIL OFFICE,

6 Empire State Plaza, Albany, NY 12228. Information for obtaining DMV records and FOIL forms is available online at:

www.dmv.ny.gov.

DMV USE ONLY

WHAT RECORDS ARE REVIEWED

I affirm under penalty of perjury that all of the information on this form and all supporting documents submitted with this appeal are true, and that no prior

appeal has been filed in this matter.

SIGN AND DATE YOUR APPEAL

BE SURE THAT YOU:

IN THE SPACE BELOW YOU MUST STATE IN DETAIL THE REASON(S) FOR THIS APPEAL and for needing a stay (if requested). PLEASE TYPE OR

PRINT CLEARL

Y. Attach additional pages, if necessary, and write your name on every page. Personal appearances and oral agruments are not permitted

on appeal. If a transcript is ordered, you will have 30 days to submit additional arguments from the date of the transcript invoice. After the 30-day period,

your appeal will be reviewed and decided. You will receive written notification of the outcome of the appeal.

APPEAL ARGUMENTS

o Pay the non-refundable appeal fee of $10 for EACH case appealed. Enclose a check or money order payable to “Commissioner of Motor Vehicles”.

o Submit your appeal form and appeal fee(s) to the Appeals Board within 60 days of the date of your order or notice.

o Provide reasons for your appeal on page two. If requesting a stay, provide reasons for a stay request on page two.

o Sign and date your appeal form on page two.

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