EXTENSION TO PAY REQUEST FORM
Print name as it appears on your driver’s license or ID
*
Driver’s license or ID number
*
DL or ID State
Address
*
Address
Street Address Line 2
City
State
Zip Code
Daytime Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Citation Number
*
Date of Citation
-
Month
-
Day
Year
Date
Appearance Date
/
Month
/
Day
Year
Date
Plea
*
I hereby enter a plea of Guilty and waive appearance for trial and request an extension to pay fine
I hereby enter a plea of No Contest and waive appearance for trial and request an extension to pay fine
Signature
*
Date of Signature
*
/
Month
/
Day
Year
Upload a copy of Driver License of State Identification Card
*
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