Steuben County District Attorney s Office
Driver Safety Diversion and Reduction Program Affidavit / Application
Name:Address:
Email/Phone:
Town of Offense(s) Occurred:
What was the ticket(s) for:

This traffic ticket is a NON-Moving violation ticket. At this time I request a possible reduction WITHOUT the accessed ADMINISTRATION FEE. Please COMPLETE the whole application to be considered.
I,_________ the defendant, born on ______________ request to participate in the
Steuben County Driver Safety Diversion and Reduction Program to avoid points and penalties associated with my traffic infraction(s). I understand that my acceptance into the program is discretionary and is decided by the program. I hereby apply as a participant in the Driver Safety Diversion and Reduction Program and waive my speedy trail rights.
I, further understand that there is an accessed ADMINISTRATION FEE of either two hundred and fifty dollars ($250.00) or one hundred and fifty dollars ($150.00), and if notified of acceptance into the program. I will be required to submit the accessed administration fee along with the Course Attendance Form, in order to be admitted into the program.
Application Questions: Please answer the following questions, Yes or No
False statements made in the foregoing instrument are punishable as a Class A misdemeanor pursuant to section 210.45 of the Penal Law.
1.Have you been convicted of driving under the influence offenses (DWI, DWAI, DWAI-Drugs), Vehicular Homicide, Involuntary Manslaughter, within the past 10 years? Yes _______ or No ______
2.Have you been convicted of any traffic related offenses within the last 18 months? Yes ______ or No ______
3.At the time of the offense were you operating the motor vehicle with either a suspended driver s license or suspended insurance? Yes ______ or No ______
4.Were you involved in an accident at the time of the offense? Yes ____ or No ____. If YES please include an insurance claim report of all payouts made to people involved in the accident in question. Contact your insurance agent for report
Mitigating Circumstances
The defendant states that at the time of the offense, one or more of the above statements were marked YES. Please give a brief statement to the circumstances. 
At this time I would like to request a review for the online course due to the following reasons. Use the back of this sheet for additional space if necessary.
All Defendants must send : |
To: Steuben County District Attorney s Office |
1. |
This application ; completed |
Attn: Driver Safety Diversion and Reduction Program |
2. |
A copy of the traffic ticket(s); |
3 East Pulteney Square |
3. |
Abstract of Driving Record from your state DMV |
Bath, NY 14810 |
|
http://dmv.ny.gov/dmv-records/get-my-own- |
|
|
driving-record-abstract |
|
4. |
A self-addressed stamped envelope |
|
**You will be notified by mail or email within 15 to 20 days if you are accepted into the program.**
DO NOT call the DA s Office in regards to the status of your application until 15 days after mailing.
***False statements made in the foregoing instrument are punishable as a Class A misdemeanor pursuant to section 210.45 of the Penal Law. Accordingly and with notice of the foregoing I hereby affirm that the foregoing statements are true, under penalty of perjury this ______ day of ________________, 20___.***
_____________________________________ |
_____________________________________________ |
SIGNATURE OF DEFENDANT |
PRINT NAME OF DEFENDANT |
SCDADSDP Application Form: Revised 2014-04-08 |
|