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Traffic Deferral Pre-Qualification Form

  1. Traffic Deferral Pre-Qualification Form

    Please fill everything out completely. We will respond to your email with instructions on how to proceed.

  2. Comes now the State of Indiana by the Prosecuting Attorney for the 23rd Judicial Circuit by his Deputy Prosecuting Attorney and the Defendant and enter into this Agreement pursuant to Indiana Code 33-37-4-2.

  3. The State of Indiana agrees to dismiss the charges in the case pursuant I.C. 34-28-5-1, IF AND ONLY IF, the Defendant complies with the terms of this Agreement.

  4. Current and complete address

  5. For our reply

  6. Agreement

  7. The Defendant agrees to pay $192.50 to the Clerk of the Court, payable in cashier's check, certified check, or money order ONLY. NO PERSONAL CHECKS. This amount must be paid on the date you submit or the agreement or included with the signed agreement if you choose to mail it in.

  8. The Defendant swears or affirms under penalties of perjury:

  9. A. The defendant is not currently participating in a deferral program in any Indiana county for a traffic violation.

  10. B. That this violation is not associated with a criminal charge (misdemeanor or felony).

  11. C. That the defendant does not have a commercial driver's license (CDL).

  12. The Defendant shall not receive a ticket for moving violations in the state of Indiana for six(6) months, starting on the date this agreement is filed with the court. By signing this Agreement you understand that a failure to comply with the six month ticket-free period may result in this ticket being filed again. If this happens, the deferral fee will be forfeited and you will need to either pay the ticket or contest the ticket. You will then receive a new appearance date for this ticket. if this happens and you fail to appear it may result in a notice being sent to the Indiana Department of Motor Vehicles to suspend your license. If a notice of a new appearance date is sent to the defendant, it will be sent to the address listed above.

  13. Signature and acceptance*

    By checking the box you are accepting the above stated Traffic Deferral Agreement and all of the provisions stated in the agreement. You accept the provisions as binding and enter into this Agreement of your own free will.

  14. Today's Date

  15. Leave This Blank:

  16. This field is not part of the form submission.