This form must be typewritten or computer generated 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated fields for last, first, and middle names.
3. Input your date of birth and state of residence in the respective sections.
4. Provide your current driver's license number. If you have been licensed in another jurisdiction, indicate 'Yes' or 'No' and fill in the previous state's information if applicable.
5. Fill out the details regarding the incident, including the date, location (city, county, state), law enforcement agency involved, court details, case number, and citation number.
6. Clearly write out the initial charge without citing any statute or ordinance number. Include the initial court date and any amended charges if applicable.
7. Describe what actions were taken following the incident (e.g., paying fines or performing community service).
8. Finally, provide a detailed narrative of the incident. Be sure to include all relevant names and events. Attach additional sheets if necessary.

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