[ ] 17th Judicial Circuit in and for Broward County Florida [ ] In the County in and for Broward County

CLOCK IN

DIVISION: [ ] Criminal [ ] Traffic [ ] Other

AFFIDAVIT OF IDENTITY

AND WRITTEN PLEA OF NOT GUILTY

THE STATE OF FLORIDA VS. PLAINTIFF DEFENDANT

CASE NUMBER/ CITATION NUMBER

AFFIANT’S NAME: SEX: ADDRESS: HOME TELEPHONE: SOCIAL SECURITY # : DATE OF BIRTH: RACE: HEIGHT: DRIVER LICENSE # : STATE: PLACE OF EMPLOYMENT: VEHICLES DRIVEN BY YOU: STATEMENT: I DENY EVER HAVING RECEIVED THIS CITATION BECAUSE: EXPLAIN WHY YOU COULD NOT HAVE BEEN CITED FOR THIS VIOLATION, AND YOUR WHERE-ABOUTS AT THE TIME THE CITATION WAS ISSUED ON A SEPARATE SHEET OF PAPER AND ATTACH WITH ALL OTHER SUBSTANTIATING DOCUMENTS, OR ATTACH A NOTARIZED AFFIDAVIT/LETTER FROM YOUR EMPLOYER, IF YOU WERE AT WORK ON THE DATE AND TIME IN QUESTION. DO YOU KNOW WHO IS USING YOUR NAME? [ ] YES [ ] NO HOW DO YOU KNOW THIS PERSON USED YOUR NAME? (IF YES, GIVE ANY INFORMATION THAT MAY BE HELPFUL TO THE COURT IN DETERMINING THE PERSON INVOLVED WITH THIS CITATION.) NAME: DATE OF BIRTH: ADDRESS: HOME TELEPHONE: PLACE OF EMPLOYMENT: EMPLOYER’S ADDRESS: DID YOU FILE A POLICE REPORT OF STOLEN PROPERTY, WALLET, PURSE, DRIVER LICENSE, ETC? [ ] YES [ ] NO (IF YES, ATTACH A COPY OF THE REPORT) SWORN TO AND SUBSCRIBED BEFORE ME THIS _________________ DAY OF AFFIANT’S SIGNATURE ________________________, 20______ DEPUTY CLERK NOTARY PUBLIC FORM.621 SEARCH FEE: 698 COPY FEE: 699