This form contains 36 fields organized into 12 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Case Caption and Case Number
Defendant Name Text
Enter the full name of the defendant as it should appear on the case caption.
Case Number Text
Enter the official court case number or docket number assigned to this matter (include letters and dashes if present).
Case Identifiers
Citation Number Text
Enter the citation or ticket number exactly as shown on the traffic citation.
Case Number Text
Enter the court case number assigned to this matter as it appears on court documents.
Court Clerk Due Date and Bail Info
Due Date (receipt of form and any unpaid bail) Date
Enter the date by which the court clerk must receive this form and any unpaid bail.
Bail Amount Required Number
Enter the bail amount required for this case.
Bail Amount Already Deposited Number
Enter the amount of bail the defendant has already deposited, if any.
Date Mailed or Delivered by Clerk Date
Enter the date the clerk mailed or delivered the documents.
Clerk/Court to Send To (specify) Text
Specify the name or branch of the court to which the clerk should mail or deliver the completed form and evidence.
Mailing Address (court) Text
Provide the full mailing address for the court (street address, city, state, and ZIP) where the completed form and evidence should be sent.
Court Information
Court Name Text
Enter the official name of the court handling the case (for example, 'Superior Court of [County]').
Court Street Address Text
Provide the street address of the court location, including building number, street name and suite or room if applicable.
Court Mailing Address Text
Provide the mailing address where correspondence to the court should be sent (P.O. Box or street address).
City and ZIP Code Text
Enter the court's city followed by the ZIP code (for example, 'Cityname, CA 12345').
Court Branch Name Text
Enter the specific branch, division or location name of the court (for example, 'Family Law Division' or 'Downtown Branch').
Declarant Name and Mailing Address
Declarant Name Text
Enter the full name of the person making this declaration as it should appear on the form.
Current Mailing Address Text
Enter the declarant's complete current mailing address, including street, city, state, and ZIP code.
Declaration Signing Details
Number of pages attached Number
Enter the number of additional pages you have attached to this declaration as a whole number.
Date of declaration Date
Enter the date when you signed the declaration.
Declarant name (type or print) Text
Type or print your full name exactly as you want it to appear as the person making this declaration.
Defendant Name
Defendant Name Text
Enter the defendant's full legal name as it should appear on the citation (e.g., last name, first name, middle name or initial).
Evidence - Additional Details
Evidence — Additional details Text
Enter a clear, concise description of any additional evidence not listed (for example: item type, quantity, file/photo names, dates, locations, witness names, and any notes explaining how the evidence supports your case). Fill only if 'other (specify)' is 'Yes'.
Max length: 500 characters
Depends on: other (specify)
Evidence - Document/Item Types
medical record Checkbox
Check this box if you are submitting one or more medical records as evidence in support of your case.
registration documents Checkbox
Check this box if you are submitting vehicle registration or other registration documents as evidence.
inspection certificate Checkbox
Check this box if you are submitting an inspection certificate as evidence.
diagram Checkbox
Check this box if you are submitting a diagram (for example, a sketch of the incident) as evidence.
car repair receipt Checkbox
Check this box if you are submitting a car repair receipt or estimate as evidence of damage or repairs.
insurance documents Checkbox
Check this box if you are submitting insurance documents (policies, claims, correspondence) as evidence.
other (specify) Checkbox
Check this box if you are submitting a different type of evidence not listed above, and specify what it is.
Evidence - Photographs
photographs (specify total number) Checkbox
Check this box when you are submitting one or more photographs as evidence and will specify the total number of photographs being provided.
Photographs — total number Number
Enter the total number of photographs you are submitting as evidence (write the numeric count). Fill only if 'photographs (specify total number)' is 'Yes'.
Depends on: photographs (specify total number)
Form Actions
Print this form Button
Save this form Button
Clear this form Button
For your protection and privacy, please press the Clear This Form button after you have printed the form Button
Statement of Facts Narrative
Statement of Facts Narrative Text
Enter the full written description of what happened, including dates, times, involved parties, and an explanation of all evidence referenced in item 5 that supports your case.