2. Administrative Review - Good Cause
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Phone number:*
16. Email*
18. Cases to be considered?*
20. Please grant the following request(s):*

    1. Remove the FTA(s)
    2. Set case on time-payment plan
    3. Reschedule my court hearing
    4. Remove case(s) from collections
    5. Ability to Pay hearing
    6. Other (describe below)
22. If "other" was selected above, describe here.
24. Statement of defendant:*
26. After completing the above, please READ and ELECTRONICALLY SIGN, below.
28. I certify under penalty of perjury under the laws of Washington State that I have read the foregoing statements in the application, know the contents thereof, and believe them to be true and correct. (Perjury is a criminal offense-see Chapter 9A.72 RCW).
30. Electronic Signature Agreement*

    1. I agree. Electronic Signature.

    By checking the "I agree" box above, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
31. Electronic Signature of Defendant*
    Last name, first name, middle initial
33. Date signed:
    Date signed:
34. City where electronically signed:*
35. State where electronically signed:*
39. COURT USE ONLY - Judge's Notes
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field