Fillable Police Amendment/VOID/ Dismissal Form (Vermont Judiciary)

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Police Amendment/VOID/ Dismissal Form (Vermont Judiciary)

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Vermont Judicial Bureau
P.O. Box 607, White River Junction, Vermont 05001
(802) 295-8869 / JUD.VJB@vermont.gov
POLICE AMENDMENT/VOID/DISMISSAL FORM
Defendant's Name Department #
Complaint # ________________________
This complaint is hereby dismissed with prejudice.
This complaint is hereby voided.
This complaint is hereby amended as follows: __________________________________________________________ or as set forth below.
Waiver of points - all conditions set out in 23 V.S.A. § 2501(b) are met.
(enter as necessary)
In violation of:
State Statute Citation
Local Ordinance Citation
Code
Actual/Posted Speed
Blood Alcohol Level
Waiver Penalty & Surcharge
$
No. of Points:
Accident Resulting? Yes No
Fatality Resulting? Yes No
Criminal Charges Resulting? Yes No
Police Supervisor (for dismissal) Date Issuing Officer Date
I
hereby plead to the above amended complaint:
Admitted
No Contest
Denied Defendant Date
500-00702 - Police Amendment Void/Dismissal (07/2017)
Distribution: Original ~ Judicial Bureau 2nd Copy ~ Defendant
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Police AmendmentVOID Dismissal Form (Vermont Judiciary)

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Completed 16 July 2020

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