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2. I (first and last name),
4. Hereby request a trial for the following charges:
6. Ticket #:
7. Officer:
9. Ticket #:
10. Officer:
12. Ticket #:
13. Officer:
15. Current mailing address
17. City
18. State
19. Zip Code
21. Phone number
22. Email address
24. My attorney is:
26. Attorney address
28. City, State, Zip
29. Attorney phone number
31. Please check each of the following showing that you understand your responsibility:

    1. 1. It is my responsibility to notify the Court of any change of address. This must be done in writing to the Court. (Note: You can use an online form for this too.)
    2. 2. The Court will send one certified notice by mail to the address that I have provided to the Court, and this it is my responsibility to accept such notice.
    3. 3. The Court on said notice will provide me with a jury selection date & time.
    4. 4. Should I fail to attend or contact the Court prior to the date & time provided by the Court, I will waive my right to a jury trial, & I consent to the Court conducting a bench trial in the absence.
    5. 5. I understand that it is my responsibility to notify the Court whether or not I have obtained an attorney for my defense. I understand that I must inform the Court of my attorney's name & address.
33. 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.
35. Electronic Signature of Defendant
36. Date signed by Defendant
40. Court official name
41. Date signed by court official
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field