Form Center

4. Citation Number(s)*
6. First Name*
7. Last Name*
9. Address1*
11. Address2
13. City*
14. State*
15. Zip*
17. Phone Number*
18. Email Address*
20. I admit that I am responsible for committing the violation(s) but I do not have the current ability to pay the fine(s) in full.*

    1. I agree
22. I am asking the Judge to:*

    1. Reduce my fine(s).
    2. Set up a payment plan.
    3. Allow community service instead of paying a fine.
24. Do you receive state or federal public benefits (including, but not limited to: Temporary Assistance for Needy Families (TANF), Supplemental Social Security Income (SSI), medical care services under RCW 74.09.035, Medicaid, pregnant women assistance benefits, poverty-related veterans' benefits, food stamps or food stamp benefits transferred electronically, or refugee resettlement benefits)? *

    1. Yes
    2. No
26. Are you currently employed?*

    1. Yes
    2. No
28. If you are employed, please check the box below that accurately describes the number of people who depend on you for support and the level of income you receive before taxes: *

    1. I have no dependents and my income is less than $18,825.00 per year ($1,568.75 per month)
    2. I have one (1) dependent and my income is less than $25,550.00 per year ($2,129.17 per month)
    3. I have two (2) dependents and my income is less than $32,275.00 per year ($2,689.58 per month)
    4. I have three (3) dependents and my income is less than $39,000.00 per year ($3,250.00 per month)
    5. I have four (4) dependents and my income is less than $45,725.00 per year ($3,810.42 per month)
    6. I have five (5) dependents and my income is less than $52,450.00 per year ($4,370.83 per month)
    7. I have six (6) dependents and my income is less than $59,175.00 per year ($4,931.25 per month)
    8. I have seven (7) or more dependents and my income is less than $65,900.00 per year ($5,491.67 per month)
    9. None of the above apply
30. If you are unemployed, are you receiving unemployment benefits?*

    1. Yes
    2. No
32. I certify under penalty of perjury under the laws of the State of Washington that the foregoing statement is true and correct.
34. After completing the above, please READ and ELECTRONICALLY SIGN, below.
36. Electronic Signature Agreement:*

    1. I agree. Electronic Signature.

    By checking the "I agree" box above, 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.

37. Electronic Signature*

    Last name, first name, middle initial

39. Date signed:
    Date signed:
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field