I certify that I am eligible for court supervision and driver safety program under the eligibility requirements.
I am requesting that the Court place me on supervision for the enclosed traffic violation.
I further understand that I do hereby PLEAD GUILTY to said offense as charged, WAIVE my constitutional rights as set forth in the traffic charge received, AND that my plea of guilty will be accepted and a conviction entered if my driving record indicates I have been placed on Court Supervision for a traffic ticket issued within 12 months of the current violation date.
I further understand that if I am not eligible OR fail to timely complete the Driver Safety Program OR Violate the law for another traffic violation within my court supervision period OR fail to pay the appropriate fine, cost, or fees, that a conviction will be entered against me and reported to the Secretary of State for inclusion of my driving records, and my fee WILL NOT BE REFUNDED. Your current ticket must indicate that no court appearance is required.