Mv3617 Form – Fill Out and Use This PDF

A Mv3617 Form is an official document that you fill out when making a claim with your automobile insurance company. This form lets the insurer know what damage was done to your car and whether or not you feel it's worth repairing.

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Mv3617 Form PDF Details

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Question	Answer
Form Name	Mv3617 Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	46
Avg. time to fill out	9 min 31 sec
Other names	wisconsin ignition interlock exemption form, mv3617, mv3617 order for ignition interlock exemptions, mv3617 wisconsin

12

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ORDER FOR IGNITION INTERLOCK EXEMPTIONS AND REMOVING TITLE TRANSFER STOPS

Wisconsin Department of Transportation (WisDOT)

MV3617

5/2015

s. 342.12(4) and s. 343.301 Wisconsin Statutes

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	Court Name																											5 Digit Court Code															County


	Driver License Number																								Court Case Number																		Citation Number


	1	2	3	4				5	6	7	8				9	1 0	11	12				13	14
	Defendant Name																									Birth Date																	Sex		Violation Date (m/d/yyyy)
																																											 Female
																																											 Male
																												M M					D D					Y Y Y Y					 Male
	Address																								City									State									ZIP Code

Nothing in this order permits the defendant to operate the vehicles identified below while his/her operating privilege remains restricted unless ignition interlocks are installed and used in the vehicles; the court’s order restricting the driver to operating only vehicles equipped with ignition interlock devices remains unchanged.

IGNITION INTERLOCK EXEMPTION





Exempt all mopeds and motorcycles for which the defendant’s name appears on the vehicle’s certificate of title or registration at the

time of this order from ignition interlock

Exempt vehicle(s) listed below from ignition interlock:

	Year	Make	Vehicle Identification Number (standard VIN has 17 characters)																			License Plate Number
 Not Exempt



				1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17			1 2 3 4 5					6	7	8
	Year	Make	Vehicle Identification Number (standard VIN has 17 characters)																			License Plate Number
 Not Exempt



				1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17			1 2 3 4 5					6	7	8
	Year	Make	Vehicle Identification Number (standard VIN has 17 characters)																			License Plate Number
 Not Exempt



				1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17			1 2 3 4 5					6	7	8
	Year	Make	Vehicle Identification Number (standard VIN has 17 characters)																			License Plate Number
 Not Exempt



				1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17			1 2 3 4 5					6	7	8
	Year	Make	Vehicle Identification Number (standard VIN has 17 characters)																			License Plate Number
 Not Exempt



				1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17			1 2 3 4 5					6	7	8
	Year	Make	Vehicle Identification Number (standard VIN has 17 characters)																			License Plate Number
 Not Exempt



				1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17			1 2 3 4 5					6	7	8

REMOVE TITLE TRANSFER STOP

The court hereby authorizes release of any title-transfer stop imposed by the department under Wis. Stat. s. 342.12(4) for the vehicles identified below.

Year

Make

Vehicle Identification Number (standard VIN has 17 characters)


1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17

License Plate Number


1	2	3	4	5	6	7	8

Reason for Denial

FAX completed form to (608) 267-6966

OR MAIL to:

Vehicle Records – OWI

Wisconsin Department of Transportation

PO Box 8070, Madison, WI 53708-8070

X

FOR QUESTIONS, call (608) 266-1466	(Judge’s Signature)	(Date – m/d/yyyy)
FOR QUESTIONS, call (608) 266-1466

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Provide the expected details in the Year, Make, Year, Make, Year, Make, Year, Make, Not, Exempt Not, Exempt Not, Exempt Not, Exempt License, Plate, Number License, Plate, Number and License, Plate, Number box.

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