PORT ORCHARD MUNICIPAL COURT STATE OF WASHINGTON 216 Prospect Street Port Orchard, WA. 98366 (360) 876-1701 CITY OF PORT ORCHARD, NO. Plaintiff, vs. ____________________________________, Defendant. DECLARATION OF NON-DRIVING STATUS FOR DEFERRED PROSECUTION I, __________________________, defendant/petitioner in this matter, say the following: 1. That I understand I am not authorized by this court to drive during this Deferred Prosecution without first obtaining the prior permission of this Court which would include showing compliance with RCW 10.05.140 (re: valid operator’s license, automobile insurance, ignition interlock, and restitution, if applicable) and the included reference RCW 46.29.490 (re: liability insurance). 2. That my failure to comply with the above requirements will constitute a violation of RCW 10.05.140. 3. I certify or declare that I have read the foregoing statement and certify under penalty of perjury under the laws of the State of Washington, that I understand it and that it is true and correct to the best of my knowledge and belief. DATED this _____ day of ____________________ 20_______. __________________________________ Petitioner _____________________________ Witness DECLARATION OF NON-DRIVING STATUS – Page 1 ________________________________ Witness (REV. 1/1/2011) ATTACHMENT B American LegalNet, Inc. www.FormsWorkFlow.com