MUNICIPAL COURT
104 GRADY TUCK LANE• BASTROP, TEXAS 78602

DEFENSIVE DRIVING REQUEST FORM

• I hereby plead NO CONTEST to the attached moving traffic citation and request that the Court defer proceedings in my case so that I may complete an approved driving safety course, present a Certificate of Completion and copy of my driving record, and have the Court dismiss my case.
• I have a valid Texas Driver's License or Permit, or U.S. Military Active Duty.
• I was not charged with speeding 25 miles per hour or more over the posted limit.
• I have not completed a driving safety course within 1 year of the date I received the citation.
• I swear I am not taking a driving safety course nor completed one that is not yet reflected on my driving record.
• I understand that I must provide proof of financial responsibility (Liability Insurance) to the Court with this request.
• I further understand that this form must be signed, notarized, and sent to the correct office with the fee by the due date on my citation to be eligible for defensive driving.
  **NOTE** HOLDERS OF CDL LICENSE ARE NO LONGER ELIGIBLE FOR DEFENSE DRIVING OR DEFERRED DISPOSITION WHETHER THE DRIVER WAS IN A COMMERCIAL VEHICLE OR IN A PERSONAL VEHICLE.

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PRINT  NAME  AS  SHOWN  ON  LICENSE                               SIGNATURE
ADDRESS _______________________________________________
HOME PHONE _______________WORK PHONE ___________________
CITY _______________________STATE ________________ZIP ____________

Under pain or penalty of perjury, _____________________________________ Sworn to and subscribed before me, the undersigned authority, on this the _______________ day of ______________,20_____.

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Notary Public in and for the State of Texas

Complete and sign this notorized form and return to the Bastrop Municipal Court, 104 Grady Tuck Lane, Bastrop, Texas 78602.