F
TRAFFIC VIOLATIONS BUREAU (TVB) APPEAL FORM
FILE TVB TICKET APPEALS ONLINE AT: dmv.ny.gov/WebAppeals/
Failure to sign and complete all applicable sections of this form will result in the rejection of your appeal. Type or print clearly.
APPEAL FILING REQUIREMENTS:
1. Mail a SIGNED, COMPLETED APPEAL FORM AND A $10.00 NON-REFUNDABLE APPEAL FEE FOR EACH TICKET YOU WANT TO APPEAL TO:
NYS DMV APPEALS BOARD, P.O. BOX 2935, ALBANY, NY 12220-0935
2. Do NOT send cash. Send a check or money order payable to the “Commissioner of Motor Vehicles.” Multiple appeal fees should be combined in one
check or money order. Print TVB ticket number(s) on your check or money order. A $35 penalty is charged for bad checks.
3. The appeal form and appeal fee must be mailed to the DMV APPEALS BOARD
WITHIN THIRTY (30) DAYS OF THE CONVICTION OR HEARING DATE.
Late appeal forms and appeal fees will be rejected.
4. Send a separate appeal form and appeal fee for each TVB ticket appealed. Multiple appeals should be sent in one envelope. The Appeals Board will
acknowledge receipt of your appeal form and fee by letter. If you do not receive an acknowledgment within 20 days after filing your appeal, contact the
Appeals Board at the above address.
TRANSCRIPT REVIEW:
CHECK THE APPROPRIATE BOX BELOW (CHECK ONLY ONE)
¨
I WANT THE APPEALS BOARD TO REVIEW THE GUILTY DETERMINATION OF THE TVB JUDGE AND THE PENALTY.
I understand that I am required to pay the transcription company in a proper, timely manner so that the Appeals Board may review the hearing transcript
(hearing testimony and arguments) for my appeal. After receiving my appeal, the Appeals Board will send complete instructions for ordering the transcript,
and I will be required to send a $50 transcript deposit to the transcription company within 30 days of the date of the Appeals Board letter. The Appeals Board
does NOT accept transcript payments. BY LAW, if transcript payments are NOT made to the TRANSCRIPTION COMPANY in a proper and timely manner,
the only issue that the Appeals Board may review is the PENALTYIMPOSED.
¨
I ACCEPT THE GUILTY DETERMINATION and WANT TO APPEAL THE PENALTY ONLY (fine/license sanction) WITHOUT TRANSCRIPT REVIEW.
I understand that, without a hearing transcript, the Appeals Board WILL NOT review the determination of guilt, or any hearing testimony or arguments
presented at the hearing. The Appeals Board will review the appropriateness of the PENALTY ONLY.
TVB FINES:
Fines and surcharges resulting from the conviction must be paid even if an appeal is filed. Unpaid fines, surcharges, or termination fees will result in a license
suspension, which is NOT stayed by the Appeals Board. Do NOT send fine and surcharge payments to the Appeals Board. TVB fines and surcharge
payments must be sent to:
DMV TRAFFIC VIOLATIONS DIVISION, P.O. BOX 2950-ESP, ALBANY, NY 12220-0950
STAY:
¨
I REQUEST THAT THE LICENSE SUSPENSION OR REVOCATION IMPOSED AS A RESULT OF THE TVB CONVICTION BE STAYED OR STOPPED
PENDING THE OUTCOME OF THIS APPEAL. A stay will not be granted unless you provide valid reasons for your request. Attach additional pages, if necessary.
I request a stay because:
REQUIRED APPEAL INFORMATION: All appeal notices will be sent to the addresses provided on this form. YOU ARE RESPONSIBLE FOR
NOTIFYING THE APPEALS BOARD IMMEDIATELY IN WRITING OF ANY CHANGE OF ADDRESS.
Last Name First M.I.
Date of Birth
Sex
o M o F
NYS Driver
License ID Number
Month Day Year
Appeal Mailing Address (Street) APT#
City Zip Code
State
ATTORNEY FOR THIS APPEAL (If any)
ATTORNEY MAILING ADDRESS: (Street)
City State Zip Code
Violation
Ticket #
Violation Date
Month Day Year
Conviction Date
Month Day Year
Hearing Location
Hearing Time
o AM
o PM
:
Hearing Judge
DMV USE
ONLY:
FEE AMT PAID: $__________________
VIOLATION: __________________________________________________________________________
FINE AMT: $_________________ ALJ: ______________ SPEED: _______/_______
STAY: ________________________________________________________________________________
¨ Check
¨ Money Order
¨ No Fee Paid
USPM:
_______________
AA-33 (3/15)
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