Michigan Department of State SOS-257: Hearing Request
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How to Request a Hearing
Collect and submit the following documents to the
Ofce of Hearings and Administrative Oversight (OHAO).
Get Started
Request your driving record online
1
Complete your evidence package
Complete the Hearing Request Application (SOS-257).
Find a qualied evaluator to complete the Substance Use Evaluation (SOS-258).
This is required if you have been arrested for any alcohol or controlled substance related offense.
Order a laboratory report from a 12-panel urinalysis drug screen with at least
two integrity variables such as specic gravity, creatinine or pH level.
The test should screen for: cocaine, marijuana, PCP, amphetamines, opiates, benzodiazepines,
barbiturates, methadone, propoxyphene, methaqualone, ecstasy/MDMA, and oxycodone/Percocet.
Send the Community Support Letter to 3-6 friends, family members or coworkers
to complete (if you do not intend to have witnesses at your hearing).
2
Gather additional documents
• Request an interlock report from your interlock provider that
is dated within 30 days of submission (if applicable).
• Have your doctor complete the DA-4P form if you are taking
medication to treat addiction, pain, or a mental or physical health
concern that may affect your ability to drive safely.
Download the DA-4P form
• Collect certications of completion or verication of participation from
programs such as AA, other support groups, or individual counseling.
3
Sign and upload your evidence package (keep a copy of your paperwork)
Go online for faster processing:
• Applicants: https://milogin.michigan.gov/
• Attorneys: https://milogintp.michigan.gov
Mailing address: Michigan Department of State, OHAO P.O. Box 30196. Lansing, MI 48909
Fax: (517) 335-2190 Email: [email protected]
If you are having trouble using DAIS, you can email SOS-AHS@Michigan.gov and any attachments need to be sent in PDF format.
4
Wait for a Notice of Hearing
If you are eligible, you will receive a notice with the time, date, and location of your hearing.
If you are not eligible or your application is incomplete, you will be notied.
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Hearing Request
SOS-257
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Hearing Request Application
Your Contact Information
Full name (from driver’s license or state ID card)
Michigan driver’s license/state ID card number
(if known)
Address (street address) City State ZIP code
Date of birth (MM/DD/YY) Phone number (including area code) Email
Have you ever been
issued a driver’s license
in another state?
If yes, list below.
No
Which state(s)?
Driver’s license
number (if known)
Non-Michigan Residents Only
You are only eligible if you are not a Michigan resident,
the action you are appealing does not involve a fatality,
and you are attempting to clear your Michigan record.
Would you like to request an administrative review?
Yes
No
Rather than attend a hearing The Department will review your
documents and driving record to determine if your Michigan driving
record can be cleared. If you are denied, you can still request a hearing.
Your Attorney’s Contact Information
Not required if you choose to represent yourself.
Full name Bar number
Attorney’s address City State ZIP code
Phone number Email
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CLEAR FORM
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Conviction History
When was the last time you were convicted of a civil infraction,
misdemeanor or felony?
This includes any time law enforcement was involved.
Go to apps.michigan.gov/ to nd
all felony and serious misdemeanor
offenses that occurred in Michigan.
Date of occurrence (MM/DD/YYYY) Conviction
List all driving and nondriving convictions involving alcohol or controlled substances (including marijuana).
Include offenses that happened in Michigan and other states.
Date of occurrence (MM/DD/YYYY) Conviction
Have you ever been incarcerated, on probation or parole for an offense
related to alcohol or a controlled substance (including marijuana)?
This includes driving and nondriving offenses.
Yes
No
Have you ever injured
or killed someone
in a crash when
you were driving?
If yes, list below.
No
Accident date:
(MM/DD/YYYY)
Number of
individuals injured:
Number
of deaths:
Do you currently have
any pending criminal
or civil infractions
(driving or nondriving)?
If yes, list below.
No
Offense:
City, State:
Court date
(if set):
(MM/DD/YYYY)
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Substance Use History
Alcohol
Have you ever used alcohol (including beer, wine or non-alcoholic beer)?
If yes, list below. No
At your peak usage, what types
of alcohol did you use?
How often?
Daily, weekly or monthly
How much at a time?
When was the last time you
used this type of alcohol?
When was the last time you used any alcohol (including beer, wine or non-alcoholic beer)?
Date Type Amount
Drugs
Have you ever used controlled substances (including marijuana)?
If yes, list below. No
At your peak usage, what types of
controlled substances did you use?
How often?
Daily, weekly or monthly
How much at a time?
When was the last time
you used this substance?
When was the last time you used a controlled substance (including marijuana and addictive prescription drugs)?
Date Type Amount
Future
Do you intend to use alcohol or controlled substances (including marijuana) in the future?
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Treatment History
Counseling and Treatment
If you’ve attended substance abuse counseling or treatment
programs, attach verication of completion for each program.
Have you ever attended substance abuse counseling
or treatment programs?
If yes, list below. No
Type of program
Such as inpatient, intensive
outpatient, or driver safety course
Name of the program
If known
Location
City, State
Dates of participation
Start and end dates
Have you ever taken medication to stop drinking
or using controlled substances?
Such as mathadone, antabuse, buprenorphine or campral
If yes, list below. No
Type Date started Date ended
Have you ever tried abstinence to stop your alcohol or substance use?
Include all periods you intentionally stopped drinking or using drugs.
If yes, list below. No
Dates Reason for relapse
Prescription Medications
Your prescribing physician must complete a
DA-4P form for all current medications included.
Have you ever taken medication to treat addiction, pain, or a mental
health concern?
If yes, list below. No
Medication What is or was it treating? Date started
Are you currently taking it?
If not, list date of last use
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Final Details
Continuum of Care
Have you ever attended a community based or 12-step program?
If yes, list below. No
Program name Do you have a sponsor? How often?
Dates of participation
Start and end dates
Non-Michigan Residents Only
Complete this section if you live outside of Michigan.
When did you move to the state or country where you are currently living?
You must submit a copy of a utility bill, lease or bank statement with this
form as proof of residency.
Have you ever lived in Michigan?
If yes, list below. No
When did you leave?
What prompted your move?
Do you intend to move back
to Michigan?
If yes, when? No
Is there anything else you would like us to know?
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Final Details (continued)
Additional Support
Foreign language interpreter
If you need a foreign language interpreter, it is your responsibility to make arrangements to have one present at your
hearing. The interpreter must be qualied by the Michigan Department of State and cannot be a family member or
friend. If you need assistance in locating a foreign language interpreter, contact the Michigan Department of State at
888-SOS-MICH (888-767-6424).
Sign language interpreter
If you need a sign language interpreter, we will help you make the arrangements for one. Contact the Michigan
Department of State at (888) SOS-MICH (888-767-6424) or by calling the Michigan Relay Center at (800) 649-3777.
Yes, I will need a sign language interpreter.
Sign Here
You may e-sign this document.
Click document eld to sign.
UNDER PENALTY OF PERJURY, I certify that I am the applicant in this matter and that the statements set forth
in this document are true and correct to the best of my knowledge and belief. I have submitted all my evidence
(substance use evaluation, community support letters, and if required, ignition interlock report, etc.) for my
hearing. I also understand that the Department of State or Hearing Ofcer may refuse to accept additional written
evidence after I submit this afdavit.
Applicant’s name Applicant’s signature Date
Opt-in to email notications. By selecting the box, I am opting in for all notications for this case to be sent to
me only electronically. I understand I must set up an account through https://milogin.michigan.gov to receive
the notications.
Attorney’s name (if any) Attorney’s signature Date
Opt-in to email notications By selecting the box, I am opting in for all notications for this case to be sent
to me only electronically. I understand I must set up an account through https://milogintp.michigan.gov to
receive the notications.
Michigan Department of State SOS-258: Substance Use Evaluation
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Substance Use
Evaluation
SOS-258
Substance Use Evaluation
A qualied evaluator must complete this form on your behalf.
Submit this form within 90 days of your evaluation with your evidence package.
What you need to do:
1
Find a qualied evaluator to complete this form.
2
Schedule an appointment with the evaluator.
Bring your completed Hearing Request Application (SOS-257) to the appointment.
3
Sign and submit the completed form with your evidence package.
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Michigan Department of State SOS-258: Substance Use Evaluation
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Substance Use
Evaluation
SOS-258
Background Information
Contact Information
Evaluator’s name
Qualications/Degrees Phone number
Program name Program license number
Address (street address, city, state, ZIP code)
Applicant’s name (rst, middle, last) Date of birth
Applicant’s phone number Applicant’s email address Michigan driver’s license/state
ID card number (if known)
Lifetime Conviction History
List all driving and nondriving convictions involving alcohol and/or drugs.
Conviction Date of arrest Blood alcohol content or drug type
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CLEAR FORM
Michigan Department of State SOS-258: Substance Use Evaluation
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Substance Use
Evaluation
SOS-258
Lifetime Treatment History
Program Treatment
Attach treatment plans and discharge reports.
Include treatment history for all mental health diagnoses, alcohol and/or drug use.
Program type Timeframe
Name of the program,
therapist or group leader Treatment outcome
Prescription Medication
The prescribing physician must complete
a DA-4P for all prescriptions included.
Include all agonist medication and medication to treat pain, mental or
physical health that may impact the applicant’s ability to drive.
PAST
Medication
Prescribing
physician Used for
Dates used
Start and end dates
CURRENT
Medication
Prescribing
physician Used for
Dates used
Start and end dates
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Michigan Department of State SOS-258: Substance Use Evaluation
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Substance Use
Evaluation
SOS-258
Lifetime Treatment History
Lifetime Support Group History
Type
Such as AA/NA Timeframe
Frequency of attendance
Daily, weekly, monthly
Sponsor’s name
If applicable
Lifetime Abstinence History
Periods of abstinence
Start and end dates
Comments
Cause of relapse and substances used
Date of last use of alcohol
Including non-alcoholic beer
Date Comments (if any)
Date of last use of controlled substances
Including marijuana and addictive
prescription medications
Date Comments (if any)
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Michigan Department of State SOS-258: Substance Use Evaluation
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Substance Use
Evaluation
SOS-258
Diagnostic Impression
Diagnostic Impression (DSM-IV or DSM-V)
Describe all past and present alcohol, drug, and mental health diagnoses (including self-reported).
Diagnosis
Supporting facts for diagnosis
Course speciers (check all that apply):
Early Full
Remission
Sustained Full
Remission
On Agonist
Therapy
Sustained
Recovery
Early Partial
Remission
Sustained Partial
Remission
In a Controlled
Environment
Non-Applicable
Diagnosis
Supporting facts for diagnosis
Course speciers (check all that apply):
Early Full
Remission
Sustained Full
Remission
On Agonist
Therapy
Sustained
Recovery
Early Partial
Remission
Sustained Partial
Remission
In a Controlled
Environment
Non-Applicable
Diagnosis
Supporting facts for diagnosis
Course speciers (check all that apply):
Early Full
Remission
Sustained Full
Remission
On Agonist
Therapy
Sustained
Recovery
Early Partial
Remission
Sustained Partial
Remission
In a Controlled
Environment
Non-Applicable
Diagnosis
Supporting facts for diagnosis
Course speciers (check all that apply):
Early Full
Remission
Sustained Full
Remission
On Agonist
Therapy
Sustained
Recovery
Early Partial
Remission
Sustained Partial
Remission
In a Controlled
Environment
Non-Applicable
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Michigan Department of State SOS-258: Substance Use Evaluation
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Substance Use
Evaluation
SOS-258
Testing & Drug Screen
Testing Instruments
Attach the actual instrument (such
as ASI, SASSI-3, MAST/DAST) used.
TEST 1
Testing instrument used Interpretation of results
Score How do the results of this test correlate with the DSM-IV or DSM-V diagnosis?
TEST 2
Testing instrument used Interpretation of results
Score How do the results of this test correlate with the DSM-IV or DSM-V diagnosis?
Drug Screen
Attach the 12-panel drug test results and
results for any additional drug tests taken.
I referred a client to a drug screening facility.
I administered a 12-panel urinalysis drug screen and submitted a current laboratory report that
includes at least two urine integrity variables such as specic gravity, urine creatinine or pH level.
This includes: cocaine, marijuana, PCP, amphetamines, opiates, benzodiazepines, barbiturates,
methadone, propoxyphene, methaqualone, ecstasy/MDMA, and oxycodone/Percocet.
What were the results of the applicant’s 12-panel urinalysis drug screen?
If you administered an ethyl-glucurodine alcohol test, include the results.
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Michigan Department of State SOS-258: Substance Use Evaluation
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Substance Use
Evaluation
SOS-258
Prognosis & Recommendation
Applicant Prognosis
Consider the applicant’s current
living and work environments, lifestyle,
relapse history, interlock device report (if
applicable), use of addictive prescribed
medications, and any other relevant factors.
What is the applicant’s prognosis? Check one:
Poor Guarded Fair Good Excellent
Explain your prognosis in detail:
Continuum of Care Recommendations
How do you recommend the applicant stay abstinent? Check all that apply:
Mental health treatment Community support group (such as AA/NA)
Substance use treatment Other:
Explain in detail. If no recommendations, why?
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Michigan Department of State SOS-258: Substance Use Evaluation
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Substance Use
Evaluation
SOS-258
Additional Information
Is there anything else you would like to share about the applicant’s substance use history or current lifestyle?
Sign Here
I authorize the Evaluator above to furnish the information set forth on this form and to discuss the information with the Michigan
Department of State. I certify that my responses contained in this document are true and accurate to the best of my knowledge and belief.
You may e-sign this document.
Click document eld to sign.
Applicant’s name Applicant’s signature Date
As of this date, I certify that this Substance Use Evaluation is true to the best of my knowledge and belief based on information obtained from
the applicant, the applicant’s known substance use disorder and mental health history, and examination. I understand that the decision to grant,
suspend, or reinstate an individual’s driving privileges rests solely with the Department of State, which may consider other facts or conditions when
making this decision.
Evaluator’s name Evaluator’s signature Date
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Michigan Department of State Community Support Letters
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3
Community
Support Letters
Community Support Letter
At least 3 people in your community must write
a letter of support to document your sobriety.
Submit all of the notarized letters with your evidence package.
What the applicant needs to do:
1
Choose 3-6 people to write a letter on your behalf.
Ask family members, friends and/or coworkers. Ideally, people who knew you before and after you became
abstinent. Together, these letters should show who you are at home, work, and in your community. They should also
show that you are abstinent from alcohol and drugs.
2
Provide the guidance on this page to each person.
It might take some time to get all of your letters back. Don’t wait!
3
Ask each person to get their letter notarized.
4
Collect and submit the notarized letters with your evidence package.
Guidance for the letter writer
Write a detailed, unique letter that addresses each of the categories below. The purpose of this letter is to document the
applicant’s sobriety. Your letter will be used as evidence for the applicant’s case. Your honesty is essential. The letter can
be typed or handwritten. Be sure to get it notarized.
Relationship
Tell us about the applicant and your relationship to them.
Describe their relationships, how they spend their time, how long you’ve know them, and how often you see
them.
Substance Use
Describe the applicant’s past and current alcohol and drug use (including marijuana).
When was the last time they used alcohol and/or drugs? Are you aware of any social activities the applicant
participates in that involve alcohol and/or drugs?
Treatment
Describe how you’ve seen the applicant change over time.
Tell us about the applicant’s involvement in treatment or other support groups. How have you seen the
applicant change since they had their license revoked?
How to submit your letter:
1. Write or type your address and phone number on the letter.
2. Print your letter and sign it in front of an authorized notary. Go to the bank or search online for a notary near you.
Free options are available.
3. Scan and email (or mail) the notarized letter to the applicant.