2. 

   Judge's Order area above is for Internal use only.
4. Citation or Infraction number*

   Include Letters

5. Violation Date*
   Violation Date
7. Name*
   Full Name Example: Joe Smith
8. Date of Birth*
   Date of Birth
10. Email*
11. Phone Number*
    Example: (555) 555-5555
13. If the address provided in the following fields differs from the one listed on the citation, please check this box.
15. Mailing Address*
17. City*
18. State/Province*
19. Zip/Postal Code*
20. Country*
22. Statement
    If you would like the court to consider your statement before making a decision, please explain your version of the incident above. Please limit your response to 400 words or 1800 characters.
24. I hereby state as follows:
    I promise to pay the monetary penalty authorized by law or, at the discretion of the court, and reduced penalty that may be set.
    
    I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
    
    I understand that if this form is submitted electronically, my typed name on the signature line will qualify as my signature for purposes of the above certification.
    
    I have read and accept all of the conditions noted above.
26. Date*
    Date
    Today's Date.
27. Place Signed / Submitted*
    Physical location of where you are when submitting this form.
28. Signature*
    Please type in your name.
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field