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[ ] State of Washington, t I City of Bingen t I City of White Salmon, . Plaintiff, Klickitat County West District Court State of Washington No. ) ) ) ) ) ) ) ) ) ) vs. Defendant' s Request for Decision on Written Statements [ ] Mitigation Hearing [ ] Contested Hearing Defendant. To: The Clerk of the Klickitat County West District Cour! P.O. Box 435, White Salmon, w498672. 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 certiff [or declare] under the penalty of perjury under the laws of the State of Washington 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 courl (Print your name) (Sign your name) (Street or Post Office address) (City, state and zip code) ---PAGE BREAK--- WEST KLICKITAT COT]NTY DISTRICT COURT _ STATE OF'WASHINGTON 501 NE Washington Street P.O. Box 435 White Salmon, WA 98612 Tel. 509-493-1 190 NO _ State of Washington _ City of Bingen City of White Salmon Infraction - Deferred Finding Defendant STATEMENT OF RESPONDENT I understand that the court will defer the entry of a "finding of committed" in this case for a period of six months. I further understand that this infraction shall be dismissed at the end of the deferral period, provided that I pay a court administration fee of $150.00 prior to commencement of the deferral period and do not commit any further infractions or criminal traffic offenses during the deferral period.* I also understand that if I am an out-of-state driver I must provide the court with a valid copy of my Department of Licensing driving record at the end of the deferral period, or appear in court. Should I fail to comply with any condition set out in the order signed by the court, the court will find this infraction committed and may enforce the entire penalty stated on the Notice of Infraction and impose a Failure To Appear assessment. I hereby waive any right I have to a speedy hearing, including the rights I have under IRL2.6. I understand that I am entitled to only one deferral in a seven-year period in the State of Washington, and confirm that I do not have a Commercial Driver's License. DATE RESPONDENT Mailing Address City State zip * If deferral is requested/granted by mail or via phone, payment of administration fee must be delivered to court with this form.