Citation Numbers: _______________, _______________, _______________, _______________
I make a plea of: GUILTY NOLO CONTENDERE (Must select one)
I understand that the citations listed on this form will be reported to the Department of Public Safety as a
conviction unless a Deferred Disposition request form is submitted to the Judge at the same time as this
request. I understand that I have the right to a trial before the court or a jury of my peers and I hereby
waive that right and wish to plead to the case(s) and make final disposition. Juveniles (16 and under)
and minors (17 and under charged with tobacco offenses or 20 and under charged with alcohol
offenses) may not pay by credit card until they have appeared in court before the Judge.
I hereby authorize the City of Bedford Municipal Court to charge the amount of $_______________ to the
Credit/Debit card listed below. My signature below confirms that I have full authority to use the card
listed below and do so voluntarily and waive my right of chargeback.
I understand that should this charge be disputed or unpaid for any reason, that all charges on this form will
be put into warrant status immediately.
_________________________________________ _____________________________________
Signature of Defendant Date
_____________________________________________________________________________________
Print Name, Address – City, State, Zip Code, and Phone Number of Defendant
Credit/Debit Cards Accepted: MasterCard Visa
_________________________________________ _______________ __________
Credit/Debit Card Number Expiration Date CVV code
_________________________________________ _____________________________________
Cardholder’s Signature (if other than Defendant) Print name as it appears on Credit/Debit Card
After all information has been completed, MAIL or EMAIL this form to:
Bedford Municipal Court
2000 Forest Ridge Drive
Bedford, Texas 76021
www.municipal.court@bedfordtx.gov
INFORMATION LINE (817) 952-2150
2000 FOREST RIDGE DRIVE ∙ BEDFORD, TEXAS
76021 Web: www.bedfordtx.gov
BEDFORD MUNICIPAL COURT
PLEA AND PAYMENT BY CREDIT/DEBIT CARD
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