officer or the Judge will determine the appropriate civil penalty and decide whether to adjudicate
me guilty.
☐ I have been charged with driving with a suspended ( or revoked) driver’s license. I hereby
request that the citation be dismissed because my license was either not suspended or was
suspended in error. I have attached proof that my license was valid at the time of the alleged
offense.
4. Defendant’s Statement: (additional papers, documents, photos, etc. may be attached, but should
be mentioned herein. Separate sworn affidavits of other witnesses may also be submitted.)
___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
I understand that any material misrepresentation could cause me to be prosecuted for a separate criminal
law violation.
____________________________
______________________________
Date
Affiant/Defendant
Sworn to (or affirmed) and subscribed before me, the undersigned authority, on this _______day
of ________________, 20_____.
☐Personally known
__________________________________________
☐Produced identification
Notary Public, Deputy Clerk, or Other Authority
_________ Type of ID Produced
Name: ___________________________________
Commission No: ___________________________
Commission Expires: _______________________
Note: It is your responsibility to make sure this affidavit is in the Court file before the hearing date.
If Affiant/Defendant is under the age of 18 years of age, a parent or guardian must sign the Affidavit.
________________________________
___________________________________
Date
Parent/Guardian
2