Court Judge

Defendant Case #

Date of Birth DL # Social Sec. #

Street Address

City, State & Zip Code

Home # Cell # Work #

IGNITION INTERLOCK PROGRAM

Start Date End Date

Vehicle Year & Make Model Color

1. The Defendant will operate no vehicle which is not equipped with the ignition Interlock device.

2. The Defendant will have an ignition interlock device installed in the vehicle referenced above.

3. The Defendant will bear all costs for installation, maintenance, replacement of the device if lost, stolen, or damaged as well as having the device monitored by the installer at least once each sixty (60) days with a driving report summary sent regularly to the court.

4. The Defendant shall not adjust, tamper with, remove, or circumvent the ignition interlock device, the wiring of the device, or the ignition system of the vehicle(s) during this period.

5. The Defendant will be solely responsible for all breath test results obtained from the ignition interlock device, as well as for all subsequent driving test results.

SIGNATURES:

Judge/Probation Officer Defendant