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2. PUYALLUP - E-Declaration of Non-Responsibility
4. **This Declaration must be completed by the Registered Owner(s) of the violator vehicles.**
   This declaration may not be used by employers/principals to transfer responsibility to their employees/agents. As a matter of law, a vehicle registered to an employer/principal that is driven by an employee/agent remains in the "care, custody and control" of the employer/principal and thus, the employer principal is responsible for payment of the infraction penalty.
6. This declaration must be completed and submitted no later than midnight on the date the response is due, as indicated in the Notice of Infraction.

   If the declaration is not received by the due date, the infraction will be subject to late fees, transfers to a collection company, and may result in refusal by the Department of Licensing to renew your vehicle license.

   If the court has found additional documentation is needed or that you have not meet the presumption of non-responsibility then a court hearing will be scheduled and a notice will be mailed out.  

   You may contact the court within 2-3 weeks to check on the status of your case.  Please be advised, the court does not mail out a disposition form if the case is dismissed.  Have your infraction number ready when contacting the court.

8. Notice No:*
9. License Plate No:*
10. State*
12. I HEREBY STATE THE FOLLOWING:
    I received the above-referenced Notice of Infraction and was the Registered Owner(s) of the above-referenced vehicle on the date of the violation.
14. I wish to rebut the presumption that I was in care, custody or control of the motor vehicle at the time of the violation based upon the following facts:*
16. Optional Attachment
    You may attach any documents you would like the Court to review to confirm your non-responsibility.
18. First Name*
19. Last Name*
21. Address*
23. City*
24. State*
25. Zip Code*
27. Phone Number*
28. Email Address*
30. I declare under penalty of perjury under the laws of the State of the State of Washington that the information provided in this declaration is true and correct. *
    I declare under penalty of perjury under the laws of the State of the State of Washington that the information provided in this declaration is true and correct.
32. Electronic Signature - Registered Owner(s)*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
34. Electronic Signature*
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field