District Court Affidavit - City Of Alexandria (Page 2 of 2) in pdf

To the Director of Finance for the City of Alexandria, Virginia:

I, ___________________________________________, do hereby certify that I am the registered owner of a _________________________________,

(Name)

(Vehicle Year/Make/Model)

bearing license plate _______________________, for which parking citation number ___________________ for violation code _________________was

(State/License Plate Number)

issued on _________________.

(Date)

□

I hereby waive formal service of process, request that this matter be set for trial in the Alexandria General District Court (520 King Street, Room 201), and

agree to be present for trial as scheduled.

□

I understand that if I cannot be present I must call the court at 703.746.4041 to reschedule. I also understand that payment of the fine will NOT excuse me

from appearing in court.

__________________________ _____________________________________________________________

Name

Mailing Address (Street, City, State, Zip)

___________________________

________________________________

___________________________

Driver’s License State/ Number

Phone Number

Email Address

__________________________________________

________________________________

Signature

Date

For Notary Use Only

State/Commonwealth of ___________________

[ ] City [ ] County of ____________________

Subscribed and sworn to/affirmed before me this ______ day of ______________, 20____, by

_______________________________________.

(Print Name of Affiant)

My Commission expires: _____________________ Commission # _____________________

___________________________________

____________________

(Notary Public)

(Date)

For City Use Only

The above named person appeared before a Notary and made oath to the truth of the above statements. As an authorized agent of the Director of Finance for

the City of Alexandria, I hereby request, on behalf of the City of Alexandria, that you schedule a hearing for the vehicle owner listed above on the ____ day

of _________________, 20___ at 9:30 a.m. and subpoena ____________________________________________as a witness in this case.

__________________________________

___________________

(Signature)

(Date)

For Court Use Only

Attorneys Present: ___________________________________________

___________________________________________________________

(Defendant’s Attorney’s Name)

□

The Accused was this day:

And was tried and found by me: