ABC County Prosecutor/Child Support
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OFFICE OF THE PROSECUTING ATTORNEY
ELKHART COUNTY, INDIANA
INFRACTION DEFERRAL INTAKE FORM
*****PRINT CLEARLY AND LEGIBLY*******
NAME
ADDRESS
CITY
STATE
ZIP
HOME PHONE
WORK PHONE
EMPLOYER
DOB
(mm-dd-yyyy)
SS# (Last 4 digits)
LICENSE TYPE
DRIVER'S LICENSE#
STATE OF ISSUE
CIRCLE THE CORRECT ANSWER TO ALL OF THE FOLLOWING QUESTIONS
With the exception of your current ticket, have you received a traffic ticket or violation in the last 12 months?
No
Yes
Are you currently participating on a Pre-Trial or Deferral Program?
No
Yes
Are you currently on Probation or Parole?
No
Yes
Is your license currently on a Learner's permit or Probationary Status?
No
Yes
Is your license currently Suspended?
No
Yes
Was an accident involved with this ticket?
No
Yes
Did you have automobile insurance when issued this ticket?
No
Yes
Do you have pending or ever been arrested or convicted of a criminal offense? (list all below)
No
Yes
***IF YES, LIST VIOLATION/CRIMINAL OFFENSE, LOCATION AND DATE.
OUT OF STATE DRIVERS
*** YOU MUST PROVIDE A COPY OF YOUR 5 YEAR DRIVING RECORD WITH THIS FORM, IF YOU DO NOT HAVE AN INDIANA DRIVER'S LICENSE!***
I AFFIRM UNDER THE PENALTY OF PERJURY AS SPECIFIED IN INDIANA CODE 35-44.1-2-1, THAT THE FOREGOING REPRESENTATIONS ARE TRUE AND CORRECT.
Signature
Click here to sign
Date
(mm-dd-yyyy)
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