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2. CIVIL INFRATION PLEA
4. Ticket #*

   Please include the letter in front of your ticket number if there is one.

5. Date of Alleged Civil Infraction*
   Date of Alleged Civil Infraction
7. Last Name*
8. First Name*
9. Middle Name
11. Address*
13. Apartment*

    1. Apartment
    2. Lot

    1. Upper
    2. Lower

    1. Suite
    2. Other

    1. N/A
15. Apartment #
16. Lot #
17. Suite #
18. Other
20. City*
21. State*
    -- Select One --ALAKAZARASCACOCTDEDCFLGAGUHIIDILINIAKAKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPAPRRISCSDTNTXTTUTVTVAVIWAWVWIWY
22. Zip Code*
24. Phone number*

    Please provide the best number to reach you at if needed.

28. CHARGE 1*

    1. N/A
    2. ADMIT RESPONSIBILITY - I enter my appearance, waive my right to a hearing and I ADMIT RESPONSIBILITY for the civil infraction alleged on the front of my citation.
    3. ADMIT RESPONSIBILITY WITH EXPLINATION - I enter my appearance, waive my right to a hearing and ADMIT RESPONSIBILITY WITH EXPLANATION for the civil infraction alleged on the front of this citation.
    4. DENY RESPONSIBILITY - I DENY RESPONSIBILITY and request a hearing.
30. CHARGE 2*

    1. N/A
    2. ADMIT RESPONSIBILITY - I enter my appearance, waive my right to a hearing and I ADMIT RESPONSIBILITY for the civil infraction alleged on the front of my citation.
    3. ADMIT RESPONSIBILITY WITH EXPLINATION - I enter my appearance, waive my right to a hearing and ADMIT RESPONSIBILITY WITH EXPLANATION for the civil infraction alleged on the front of this citation.
    4. DENY RESPONSIBILITY - I DENY RESPONSIBILITY and request a hearing.
32. CHARGE 3*

    1. N/A
    2. ADMIT RESPONSIBILITY - I enter my appearance, waive my right to a hearing and I ADMIT RESPONSIBILITY for the civil infraction alleged on the front of my citation.
    3. ADMIT RESPONSIBILITY WITH EXPLINATION - I enter my appearance, waive my right to a hearing and ADMIT RESPONSIBILITY WITH EXPLANATION for the civil infraction alleged on the front of this citation.
    4. DENY RESPONSIBILITY - I DENY RESPONSIBILITY and request a hearing.
34. EXPLINATION
36. I DENY RESPONSIBILITY AND REQUEST A HEARING

    1. An INFORMAL HEARING before a magistrate, referee or judge. Neither side may have an attorney.
    2. A FORMAL HEARING before a judge. An attorney will be with the officer. I may be represented by an attorney.
40. Payment Extension

    1. I am requesting a 30 day extension
44. Date*
    Date
46. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
48. Electronic Signature*
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field