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2. 
3. Instructions:

   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 appearing on either a criminal record or a driver’s license record.  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*
24. 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: 

    • I am not under the age of 17.
    • I  waive discovery pursuant to Article 39.14, C.C.P., waive my right to a trial by jury, and enter a plea of NO CONTEST or GUILTY.
    • I am providing the Court with a photocopy of my driver's license/permit or Picture ID.
    • I understand I am requesting a ONE-TIME extension of 30 days to have my fines and fees paid in full.
    • I understand the extension will begin from the date this request is made.
    • I understand the the court will send a courtesy notice advising of the due date. However, I am responsible for the full amount on the due date regardless of whether I receive the notice or not.
    • I am not charged with any offense involving minor alcohol or family violence.
    • I acknowledge that If any portion of the fines or fees is paid on or after the 31st day of this agreement, I will have a $15  time payment fee added to each outstanding violation
    • I acknowledge A JUDGMENT and CONVICTION will be entered against me in this case, and the OFFENSE WILL BE REPORTED TO THE STATE OF TEXAS AS REQUIRED BY LAW.
    • If the Court grants this request and I fail to comply with all the terms and conditions set by this Court and/or fail to appear at a Show Cause Hearing , I understand that a Capias Pro Fine warrant may be issued for my arrest. I may also be denied renewal of my driver's license until I have paid or disposed of my case.

    1. I swear and affirm I have read and understood the statement above.
26. 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
30. Proof of Driver's License/ Identification card *

    Upload proof of picture ID

32. SIGNATURE*

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

33. 
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field