Court Referral for Ignition Interlock

Name: __________________________________________	 		Date of Birth: __________________ 
Address: _______________________________________________________    	Phone#: ______________________
Driver’s License #: __________________________________   			DL State: ______________________ 
Case #: ___________________   Charge/Offense: _______________________________________________________
Court: _________________________________________	Judge: _____________________________________	
Phone: _________________________ 	Fax:   _______________________________
Law enforcement agency:  ___________________		Prosecutor:  ________________________________

Register at:

	_________________________________________ 
_________________________________________
_________________________________________
______________________, MT _______________
Phone:  __________________________________	 

	_________________________________________ 
_________________________________________
_________________________________________
______________________, MT ______________
Phone:  __________________________________	
ORDER:	
1.	 Interlock  is a condition of   bond	sentence
2.	  You must have interlock installed on every vehicle you drive and abide by the program rules.  
3.	  YOU MUST FILE PROOF OF INSTALLATION OR APPEAR IN COURT ON ___________________________,
_______________________________, 201___, at _______ __.m. and explain why you did not install interlock.
4.	  Any non-compliance will be reported to the court or monitoring agency and may result in a warrant being issued for your arrest, your driver’s license being suspended, and your bond or suspended sentence being revoked.
5.	 You must have interlock with a video installed.	
6.	 You are under further restricted driving/occupational lockout.  
a.	The allowable drive time begins at __________ and ends at ______ M, T, W, H, F
b.	The allowable drive time begins at __________ and ends at ______ S,S
7.	 You are responsible for scheduling the initial appointment, compliance, and payment for services. 
8.	 You must abide by all program rules.  
9.	 The interlock provider must email noncompliance reports to:
___________________			___________________
___________________			___________________				

															
Signature of Defendant    			   Date		              Signature of Judge				Date

___________________________________________ Office Use Only __________________________________________________  

 did	  did not  install Interlock    	Signed:  _______________________________  Dated:  _______________
						Interlock Company

cc: ____________  City Prosecutor    Defendant  Defendant’s attorney _________________	 Interlock Monitoring Co. _______________

©2015 Montana Supreme Court Commission on Courts of Limited Jurisdiction 	
This form may be used for non-commercial purposes
Approved February 20, 2015