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[ ] State of Washington, [ ] CitV of Bingen [ ] City of 'White Salmon, Plaintiff, vs. Klickitat County'West District Court State of \ilashington No ) ) ) ) ) ) ) ) ) ) Defendant. Defendant' s Request for Decision on Written Statements [ ] Mitigation Hearing [ ] Contested Hearing To: The Clerk of the Klickitat County West District Court, P.O. Box 435, White Salmon, w A 98672. From: , Defendant. (PrintName) I hereby request that the court decide my case based on my following sworn statement: ---PAGE BREAK--- (Attach additional pages if necessary) I certify [or declare] under the penalty of perjury under the laws of the State of V/ashington that the above statement is true. I promise that if it is determined that I committed the infraction for which I was cited, I will pay the monetary penalty authorized by law and assessed by the court. I understand that I may not appeal the decision ofthe court. (Print your name) (Sign your name) (Street or Post Office address) (City, state and zip code)