Montgomery County Safe Speed
PO BOX 10314
Gaithersburg, MD 20898-0314

Affidavit

I, _________________________________,

resides at ________________________________________________________, do here hereby certify that the vehicle referenced in the citation described below was being driven by the following person at the time of the alleged violation and that the following information with respect to the vehicle and driver is true and correct.

Citation Number:  ________________

Year of Vehicle:   ________________

Make of Vehicle:  ________________

License Plate Number:  ___________ State: _____________

Driver Name: ______________________________________

Driver Address:  ___________________________________________________________________

I Swear and affirm this information is true and correct to the best of my knowledge.

______________________________________                                  _________________
Signature                                                                                               Date