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