INFRACTION DEFERRAL APPLICATION
MOVING VIOLATION DEFERRAL FEE - $249.50
NON MOVING VIOLATION DEFERRAL FEE - $119.00
SEAT BELT VIOLATION DEFERRAL FEE - $18.00
Application to determine eligibility for Deferred Prosecution
DO NOT APPLY FOR DEFERRED PROSECUTION IF:
1. You have a current CDL
2. You are currently on a deferral or diversion program in any county
3. You have had an OWI / DUI in the last 6 yrs
4. You have a driving felony in the last 10 yrs
5. You have ever been convicted of an A or B felony
6. You have ever been adjudged a habitual traffic violator
7. You are under the age of 18 or have a probationary license
8. You have received two or more moving violation tickets in the past 12 months
I have answered “NO” to all of the above items and believe I qualify for this deferral program. I hereby
request permission to enter into your traffic deferral program and voluntarily furnish the following
information for your use in determining my eligibility.
DO YOU HAVE ANY OTHER CHARGES PENDING IN ANY OTHER COURT : YES -or- NO (circle one)
If YES, what charges and what court?_______________________________________________
YOUR current mailing address: ____________________________________________________
City/State/ Zip Code: ____________________________________________________________
YOUR Telephone No.____________________________________________________________
YOUR Date of Birth:_____________________________________________________________
YOUR Drivers License No. _______________________________________________________
If you have an out of state drivers license, you must provide a certified copy of your driving
record from your state Dept of Motor Vehicles when you return this form.
If your due date or court date is less than 10 days away you must contact the court to request an
extension or new court date to allow our office time to process your request. The court may order
you to pay a $25.00 late fee.
____________________________________________/______________________________________________ /____________
Signature Printed Name Date
RETURN THIS FORM ALONG WITH A COPY OF YOUR TICKET TO:
BY MAIL : BY FAX:
Morgan County Prosecutor’s Office 765-342-1085
10 East Washington Street
Martinsville, IN 46151
**If our office determines that you are eligible for the deferral program, we will mail you
the agreement that you must read, initial and sign. You must then return the completed
agreement to the court along with your fee by the date listed in paragraph number 5.
Failure to do so may cause your license to be suspended. **
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome