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2. Driver's License No.*
3. State*
4. Infraction No.*
6. Name*
   First/Last/Middle
8. Address1*
10. Address2
12. City*
13. State*
14. Zip*
16. Email*
20. I understand that I may only have ONE (1) Deferral for a moving violation and ONE (1) for a non-moving violation within a SEVEN (7) year period.
22. I HEREBY CERTIFY AND AGREE AS FOLLOWS:
24. 1. I am the person named above. I agree that I have committed the infraction(s) listed on the citation number shown above. I ask the Court to defer entry of a finding that I committed the infraction(s).
26. 2. I have not had another traffic infraction deferred by any court within seven (7) years of this date. If my infraction is for the charge of Operating a Motor Vehicle Without Liability Insurance or Expired Vehicle Tabs, I have shown the Court proof that I am now insured and that I have a current registration.
28. 3. I do not possess a CDL (Commercial Driver’s License) endorsement.
32. I AGREE TO THE FOLLOWING CONDITIONS OF MY DEFERRAL:
34. 1. I agree to pay the required Court Administrative Fee of $175 within 30 days. I may contact the court for a payment plan.
36. 2. The Court will dismiss my infraction(s) six months from the date shown below if I pay the Administrative Fee and if I do not commit a new traffic infraction in any location during this six-month period.
38. I hereby certify under penalty of perjury of the Laws of the State of Washington that my foregoing statements are true and correct.
40. 3. If I fail to pay the Administrative Fee or if I commit a new traffic infraction, the Court will, without further notice to me or hearing, enter a finding that I have committed the infraction(s) listed on the citation number shown above and will report the finding to the Washington State Department of Licensing (DOL). I will then be required to pay the full original amount of the citation in addition to the Administrative Fee immediately.
44. After completing the above, please READ and ELECTRONICALLY SIGN, below.
46. I certify under penalty of perjury under the laws of Washington State that I have read the foregoing statements in the application, know the contents thereof, and believe them to be true and correct. (Perjury is a criminal offense-see Chapter 9A.72 RCW).
48. Electronic Signature Agreement:*

    1. I agree. Electronic Signature

    By checking the "I agree" box above, 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.
49. Defendant's Electronic Signature*
    Last name, first name, middle initial
51. Signed at (city and state):*
52. Date signed:*
    Date signed:
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54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

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