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Uniform Traffic Citation
_________________________
CHECK
DIGIT
(3) S.O.
X
(4) OTHER
ISSUE DATE: <Issue Date>
FINE AMOUNT: $<AmtDue>
Location: <Location of Violation>
Violation Date and Time: <Violation Date & Time>
Vehicle License Number: <License Plate # and State>
AGENCY #______________________________
IN THE COURT DESIGNATED BELOW THE UNDERSIGNED CERTIFIES THAT HE/SHE
HAS JUST AND REASONABLE GROUNDS TO BELIEVE AND DOES BELIEVE THAT ON:
DAY OF WEEK
MONTH
DAY
NAME (PRINT)...
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