This Form Must Be Typewritten or Computer Generated 2026

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  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 details if applicable.
  5. Fill out the date of the incident, 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 (e.g., paying fines, community service) and provide a detailed narrative of the incident including names of others involved and significant events.

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