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2. The City Court Attorney operates a deferral program under the following general guidelines. Eligibility is determined by the City Court Attorney on a case-by-case basis:
   
   -Only have one moving violation for this traffic stop
   -No other prior or outstanding moving violations or deferral of a moving violation anywhere within the United States in the 6 months prior to the date of the ticket or in the time period between the ticket and the date the deferral agreement is signed by the Defendant
   -No OWI or DWI arrest in the last five years, or disposition date less than two years old
   -Does not hold a CDL license
   -Was not using a Chauffeurs license at the time of the stop
   -Speeding not more than 25 mph over the posted speed limit
   
   Under the Deferral Program, you agree to pay a deferral fee and court costs of $252.50 total, and not commit any violations for 12 months. If successful, the Court will dismiss your case and points will not be assessed on your driving record. If another violation is committed during the 12-month deferral period, judgment will be entered against you, and the Court may impose fines and costs.
   
   I hereby consent to allow the City Court Attorney to review my records with the Indiana Bureau of Motor Vehicles to confirm my eligibility for this program.*
4. Please make a selection:*

   1. Yes
   2. No
6. I hereby consent to allow the City Court Attorney to review my records with the Fishers Police Department to confirm my eligibility for this program.*

   1. Yes
   2. No
8. Please contact the City Court Attorney at 317-588-1440 if you have any questions filling out this form.
10. Ticket Number (This can be found in the top right corner of your ticket.)*
12. Date of Initial Hearing
    Date of Initial Hearing
    The date is located at the bottom of the ticket.
14. First Name*
15. Last Name*
17. Date of Birth*
    Date of Birth
19. Driver's License Number*
21. Address1*
23. Address2
25. City*
26. State*
27. Zip*
29. Phone*
31. Email*
    If you do not have an email address, please write "none" in this field.
33. Confirm Email*
    If you do not have an email address, please write "none" in this field.
35. By submitting this request, I confirm that the above information is accurate. 
    
    I understand that by submitting this application, I am still required to show up for the initial hearing date identified on my citation if my application is not approved by the initial hearing date. I understand that failure to attend my initial hearing date may result in a judgment being entered against me and suspension of my driver's license.
37. Select "Yes" to confirm. *

    1. Yes
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field