Request For Certification Of Reinstatement And Certificate Authorizing Reinstatement Of Licensing Privileges {CV-653}

Court File No. (TYPE OR PRINT IN BLACK INK) STATE OF NORTH CAROLINA IV-D Case No. County In The General Court Of Justice District Court DivisionName Of Plaintiff VERSUS REQUEST FOR CERTIFICATION Name Of Defendant OF REINSTATEMENT AND Name And Address Of Obligor CERTIFICATE AUTHORIZING REINSTATEMENT OF LICENSING PRIVILEGES Social Security No. Of ObligorDate Of BirthRace Sex G.S. 50-13.12; 110-142.2 REQUEST FOR REINSTATEMENT OF LICENSING PRIVILEGES I hereby request reinstatement of the licensing privileges listed below, which were revoked based on my failure to pay child support. I am no longer delinquent in paying court-ordered child support. Type(s) Of License License Number(s) Name And Address Of Issuing Agency N. C. Wildlife Resources Commission, 1707 Mail Service Hunting Center, Raleigh, NC 27699-1707 N. C. Wildlife Resources Commission, 1707 Mail Service Fishing Center, Raleigh, NC 27699-1707 N. C. Wildlife Resources Commission, 1707 Mail Service Trapping Center, Raleigh, NC 27699-1707 Occupational, Business or Professional Occupational, Business or Professional Occupational, Business or Professional N. C. Division of Motor Vehicles, 1100 Mail Service Driving (effective 12/1/96) Center, Raleigh, NC 27699-1100 Motor Vehicle Registration N. C. Division of Motor Vehicles, 1345 Mail Service (effective 12/1/96, IV-D only) Center, Raleigh, NC 27699-1345 Date Signature Of Obligor CERTIFICATE AUTHORIZING REINSTATEMENT OF LICENSING PRIVILEGES I hereby certify pursuant to G.S. 50-13.12(c) or G.S. 110-142(d) that the above-named obligor is no longer delinquent in child support and is eligible for reinstatement of any licensing privileges which were revoked on the basis of his/her failure to pay child support. Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court IV-D Agency CERTIFICATION I certify that this is a true copy of an original order on file in the office of the Clerk of Superior Court. Date Of Certificate Signature Deputy CSC Assistant CSC Clerk Of Superior Court IV-D Agency CERTIFICATE OF MAILING At the request of the obligor, a copy of this Order was mailed by first class mail on the date shown below to the licensing agency(ies) shown above. Date Of Mailing Signature Date Of Certificate Deputy CSC Assistant CSC Clerk Of Superior Court IV-D Agency AOC-CV-653, Rev. 3/03 2003 Administrative Office of the Courts