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2. PUYALLUP - Traffic Infraction Deferral *Request
4. *Request must be submitted to the court within thirty days (30) days from the date that you received your infraction or thirty-three (33) days if ticket mailed by the court.
6. Driver's License Number:*
7. State issued:*
8. Citation Number*
10. Last Name*
11. First Name*
12. Middle
14. Address*
16. City*
17. State*
18. Zip Code*
20. I HEREBY CERTIFY AND AGREE AS FOLLOWS:
    I am the person named above. I agree that I have committed the infraction(s) listed on the citation number shown above. I ask the Court to defer entry of a findings that I committed the infractions(s). I have not had another traffic infraction deferred by any court within the past seen (7) years. If my infraction is for the charge of Operating a Motor Vehicle without Liability Insurance, I have shown the Court proof that I am now insured.
22. I AGREE TO THE FOLLOWING CONDITIONS OF MY DEFERRAL:

    (1) I agree to pay the required Court Administrative Fee; (2) The Court will dismiss my infraction(s) at the end of the deferral period if I pay the Administrative Fee AND if I do not commit a new traffic infraction at any location during the deferral period: (3) If I fail to pay the Administrative Fee, or if I commit a new traffic infraction, the Court will, without further notice to me or hearing, enter a finding that I have committed the infraction(s) listed on the citation number shown above, impose the original penalties of the infraction(s) and will report the findings to the Washington State Department of Licensing (DOL), and if I have failed to pay the required Court Administrative Fee, the Court will assess a $52.00 penalty and notify DOL, who may begin processing my driver's license for suspension.

24. Signed at (City)*
25. State*
26. Date:*
    Date:
28. Upload Supporting Documents
30. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
32. Electronic Signature*
33. Text Reminders*

    1. Yes
    2. No

    Data rates may apply.

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

    This field is not part of the form submission.

37. Submit

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