Deferred Disposition Request No Insurance Violation

City of Austin Municipal Court

Deferred Disposition Request - Failure to Maintain Proof of Financial Responsibility Violation (No Insurance)

Case or Citation Number (only enter one case or citation number)*

Charge Description*

Date of Request*

Name as Shown on Citation*

First Name

Middle Name (optional)

Last Name

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

I hereby enter a plea of “no contest” to the violation described above and waive my right to trial. I request the Court allow me to complete a deferred disposition for this case. I understand if I successfully complete the terms of the deferred disposition by the due date established by the court, my case will be dismissed. If I do not complete the terms of the deferred disposition, I will be sent a notice to appear in court to show cause why I did not complete the terms of this deferral. If cause is not sufficient, I understand that the deferred disposition will be revoked and I will be found guilty of the offense, and the conviction will be reported to the Department of Public Safety to be placed on my driving record. A conviction of this charge remains permanently on my driving record and I understand if I have two or more convictions for Failure to Maintain Proof of Financial Responsibility in the State of Texas, my driver license may be suspended.

I understand that the deferral period is 180 days (6 months) from the date this form is submitted and agree to the terms of this deferred disposition which are:

1. The payment must be made immediately in the amount of $125.00 plus collection and/or warrant fees, if applicable. The amount due may be obtained by calling 512-974-4800. Please confirm that this request has been processed before submitting payment online. You may also pay in person at both of the court's locations, by mail, or by calling 512-974-4800. Contact the court if you cannot pay immediately; and

2. Maintain the minimum liability insurance coverage as required by law without lapse during the deferral period (attach copy of insurance or binder with this form); and

3. Possess and maintain a valid driver license or permit during the deferral period (attach copy with this request); and

4. Notify the Court in writing of any change of name or address; and

5. At the end of the deferral period, submit a letter (Letter of Experience) from your insurance company or agent showing that the above mentioned insurance has been in effect from the date this form is postmarked for a period of 180 days to the Court.

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Upload image of insurance card or binder* No File Chosen

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Defendant signed this date: *

Defendant will sign by*

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Signature*

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Signature*

First Name

Initial (optional)

Last Name

Send payment to Austin Municipal Court, P.O. Box 2135, Austin, TX 78768;

visit one of our two Austin locations: Main Courthouse, 6800 Burleson Rd., Bldg 310, Ste 175 or Jaime Padron Substation, 12425 Lamplight Village Avenue

call 512-974-4800 to make payment arrangements.

Case information is available at www.austintexas.gov/public