COLLIN COUNTY JUSTICE COURT DEFENDANT: YES [] [] [ [ ] ] APPLICATION FOR DEFERRED DISPOSITION CHARGE: TICKET #: Please answer yes or no to the following questions: NO [] [] [ [ ] ] I have a valid Drivers License or Permit (from the state of residence). 1. Are you on deferred disposition (probation) for any other citation? 2. Have you received a citation for the charge mentioned above within past twelve (12) months and had it dismissed by a deferment? 3. Have you completed an approved Driver's Safety Course in the past twelve (12) months? 4. Was there an accident involved at the time you received your citation? AFFIDAVIT I have proof of insurance, and I am listed as a driver on the insurance policy or insurance card. If under 25 you are required to take a Drivers Safety Course as part of your deferment order. PLEA I was in a non-commercial vehicle and was not going 30 mph or more than 30 mph over the posted speed limit. I hereby enter my plea of NO CONTEST or GUILTY (check one) to the offense of ___________________________________ and ask the court to grant me Deferred Disposition. Furthermore, I understand that as a condition of my deferment, I cannot commit an offense against the State of Texas while under this court order. _____________________________________________ Defendant's Signature _____________________________________________________________________________ Defendant's Physical Address _____________________________________________________________________________ Mailing Address (If different) Date ________________________ _________________________ Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com