___________________________________ Defendant's Name ______________________________ Case Number The local rules of the Yakima County District Court allow you to submit a written statement instead of appearing at the hearing, notice of which is enclosed with this form. If you wish to submit a written statement in lieu of appearing at the hearing, please use this form. It must be received by the Clerk at least one court day before the hearing. You also must provide the Clerk with a stamped, self-addressed envelope so that you can be advised as to the result of the hearing. No appeal may be taken from the result. You may attach photocopies of any documents you believe are relevant to your statement. Do not attach original documents. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ I hereby certify or affirm under penalty of perjury of the laws of the State of Washington that the foregoing is true. I promise that if it is determined that I committed the infraction(s) for which I was cited, I will pay the monetary penalty assessed by the Court. Signed this ______ day of ________________, 20_____, at _________________, WA place where signed ____________________________________ your signature Bring or mail this form to Yakima County District Court, Room 225 County Courthouse, 128 No. 2nd Street, Yakima WA 98901: Tel: 509-574-1800. Include a stamped, selfaddressed envelope. EFFECTIVE 9/1/01 UNIFORM EXEMPLAR NO. 2 American LegalNet, Inc. www.USCourtForms.com