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Trial By Written Declaration as seen on

Item	Unit price	Cost
FIGHT CALIFORNIA TRAFFIC TICKETS	$69.00	$69.00
Violation Charges		$0.00
Bank/Transaction fees		$2.76
Total		$71.76

First Name:*

Ex: John

Last Name:*

Ex: Doe

Mailing address:*

Ex: 1234 Maple street, #6

Address2:

City:*

Ex: San Diego

State:*

Zip:*

Ex: 12345

Cell Phone:*

Ex: (123)123-1234

Home Phone:

Ex: (123)123-1234

Work Phone:

Ex: (123)123-1234

E-mail Address:*

Ex: abcd@abcd.com

Indicate State where the
traffic ticket was issued to you:*

$69 Flat Fee