Extension Of Time To Pay Date* MM slash DD slash YYYY Name* Drivers License Number* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone*Date of Birth* MM slash DD slash YYYY I am requesting an extension of time to pay my infraction ticket. By requesting an extension, I understand that I am admitting and waiving my rights. I understand that the judgement will be entered against me and notification will be made to the Bureau of Motor Vehicles. I understand that this will become part of my permanent driving record.
