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2. 
3. Instructions:

   Please Submit One Application Per Violation.

   You must complete this request and submit all documentation required.  It is your responsibility to follow up with the court at 817-985-2140 to verify receipt of your request.  After your request is reviewed, the court will  e-mail and mail you a notice of your agreement. False statements to the Court will be considered perjury and referred to the Tarrant County District Attorney's office for prosecution.

   **Be aware that this request will result in a conviction. Please contact the court to see if you are eligible for other options.

5. Citation Number: *
6. Violation:*
8. First Name*
9. Last Name*
11. Date of Birth:*

    MM-DD-YYYY

13. Address*
15. City*
16. State*
17. Zip*
19. Cell/Primary Phone*
20. Alternate Phone
22. Email*
26. Employer
28. Address
30. City
31. State
32. Zip Code
36. Reference

    1. Please list one personal reference that can be contacted if you move or change employment

38. First Name*
39. Last Name*
41. Address1*
43. City*
44. State*
45. Zip*
47. Requirements*

    I, the Defendant in the above-entitled cause, do hereby enter my plea of No Contest or Guilty, waive my right to a jury trial and request a 30 day extension. 

    I swear that the following statements are true:

    1. I am at least 17 years of age.
    2. I waive discovery under Article 39.14, C.C.P., waive my right to a jury trial, and enter a plea of NO CONTEST or GUILTY.
    3. I have provided the Court with a photocopy of my driver’s license, permit, or photo ID.
    4. I am requesting a one-time, 30-day extension to pay all fines and fees in full.
    5. I understand the extension period begins on the date this request is made.
    6. I understand the Court will send a courtesy notice with the due date; however, I remain fully responsible for payment by that date, even if I do not receive the notice.
    7. I am not charged with an offense involving minor alcohol possession or family violence.
    8. I understand that if any portion of my fines or fees remains unpaid on or after the 31st day of this agreement, a $15 time payment fee will be added to each outstanding violation.
    9. I acknowledge that a judgment and conviction will be entered in this case, and the offense will be reported to the State of Texas as required by law.
    10. I understand that failure to make payments as scheduled may result in a warrant for my arrest.
        • If I cannot pay the fines and costs, I will contact the Court to discuss possible alternatives.
        • I may be required to attend a hearing and provide documentation of my financial status.
        • I understand that I must notify the Court of any changes to my financial situation that affect my ability to pay.
    11. If the Court grants this request and I fail to comply with all terms or fail to appear at a Show Cause Hearing, I understand that a Capias Pro Fine warrant may be issued for my arrest and that I may be denied renewal of my driver’s license until the case is resolved.

    1. I swear and affirm I have read and understood the statement above.
49. Plea*

    By entering a plea I, the Defendant, do hereby waive discovery pursuant to Article 39.14, C.C.P., waive my right to trial and enter my plea of (please check a box below):

    1. GUILTY
    2. NO CONTEST
53. Proof of Driver's License/ Identification card *

    Upload proof of picture ID

55. SIGNATURE*

    By signing this form in the space provided above, I hereby swear and affirm that the information provided above is correct.

56. 
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

* indicates a required field