Traffic Camera Citation Non-Responsibility Declaration Form
Use this form to declare that you were not responsible for the traffic camera citation identified below. Please provide accurate information to assist with the review process.
Citation Number
*
Citation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vehicle License Plate Number
*
Vehicle Make and Model
*
Declarant's Full Name
*
First Name
Last Name
Declarant's Contact Email
*
example@example.com
Declarant's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Last 4 Digits of Your Government-Issued ID (optional)
Basis for Non-Responsibility (Please explain why you were not responsible for this citation)
*
Declaration: I declare under penalty of perjury that the information provided above is true and correct to the best of my knowledge.
*
Submit Declaration
Submit Declaration
Should be Empty: