Declarant's name:

State the facts of the case in your own words. If you have any exhibits, explain their significance in the statement and attach. Please print clearly or attach a written statement.

By having a documentary hearing, I waive the following rights: to personally appear to present evidence; to review evidence before the hearing (Rule 13(b)); to compel production of any citing officer notes (Rule 13(c)); to testimony under oath (Rule 16(a)); to cross examine the State's witnesses (Rule 16(c)); to present rebuttal evidence Rule 19(d)); to present a closing argument Rule 19(e)); and to immediate delivery of written notice of appeal after the imposition of any civil sanction or penalty (Rule 25(a)). I acknowledge that if the court does not receive this declaration by the hearing date, a default judgment may be entered against me, a civil sanction or penalty may be imposed, the Department of Transportation may refuse to renew the registration of a vehicle of which I am the registered owner, and my case may be sent to collections.

I declare under penalty of perjury that the foregoing is true and correct.

Dated:____________________