Judicial/Administrative Review RE: Good Cause Form

Questions should be directed to 253-862-6606

What Court Jurisdiction:

Bonney Lake

Sumner

Eatonville

South Prairie

Phone Number

Case Number(s):

Statement of defendant: I understand these cases are/may be in Collection Status. Please grant the following requests:

Allow me to do community service instead of paying my fines/penalties

Set a hearing for me to present my argument to you in person

Review my written statement below in lieu of appearance

Remove the case(s) from collections and set payment plan

Waive/Reduce FTA(s) and fees to:

Reduce FTA(s) and fees to:

My request is based on the following reasons:

I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

Signed at (city and state):

Defendant's Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

OFFICIAL USE ONLY

** COURT DATE______________ AT ___________ A.M. P.M.**

RESPONSE FROM THE COURT

Your motion/request is GRANTED DENIED

______ Case(s) shall be removed from collections upon proof of clearance of all outside Department of Licensing holds. Outside holds must be cleared within _____________ days.

______ FTA fees shall be waived/reduced to _____________________.

______ No time payment plan is authorized. You must contact Puget Sound Collections at 253-566-1800 to set up payment arrangements.

______ Case(s) shall be removed from collections status and FTA's cancelled upon receipt of initial first payment of $________________ by ___________________.

______ Time payment plan is approved. Monthly payments of $_______________ is due ________________ and continues each month until paid in full. Any missed payment will result in re-referral to collection status and re-issuance of the FTA.

Date ______________ ___________________________________________

Judge / Pro tem