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NOTICE TO VIOLATORSEE REVERSE SIDEFOR INSTRUCTIONS
NOTICE TO OFFICERENTER ASSESSMENT $AND TOTAL DUE $ ONLY
IF YOU CHECK“ALL CIVIL INFRACTIONS”.ENTER COURT ADDRESS
BELOW ONLY IF YOU CHECK“CRIMINAL APPLICATION”.
MASSACHUSETTS UNIFORM CITATION
VIO
LAT
OR
CO
PY
TYPE OF CITATIONDATE WRITTEN (MM/DD/YY)
MOTOR VEHICLE LICENSE NO. OF VIOLATOR STATE CLASS RACE SEX
(Initial)
STATE ZIP
NON-INVENTORY MV SEARCH
BIRTH DATE (MM/DD/YY)CODE
YES NO CDL LICENSE
YES NOVIOLATOR NAME (Last) (First)
ADDRESS CITY / TOWN
PLATE TYPE
OFFENSE DATE (MM/DD/YY) LOCATION OF OFFENSE (include #, st, hwy, city or town)
A. CHAP/ SEC / SUB CRIMCIVIL
CRIMCIVIL
CRIMCIVIL
CIVILMPHINA
MPHZONE
POSTEDNOT POSTEDLIDAR
CLOCKEDRADARESTIMATED
DESCRIPTION OF OFFENSE
B.
C.
OFFICERCHECKONE ONLY
X
X
OFFICER CERTIFIES IN HAND TO VIOL.
ALL CIVIL INFRACTIONS(See instruction A on back)
CRIMINAL APPLICATION(See instruction B on back)
WARNING(No action required)
ARREST
MAILED TO VIOL. IN HAND TO VIOLATOR’S AGENT
AGENT NAME
AGENT’S LICENSE NUMBER & STATEVIOLATOR/ AGENT ACKNOWLEDGES RECEIPT OF CITATION
D. SPEEDING
90 /17 90/18
VEHICLE REGISTRATION NO. STATE YEAR CDL VEHICLE
YES NO
16+ PASSENGERS
YES NO
CRASH
YES NO
MAKE AND TYPE
ASSESSMENT
TOTAL DUE
COURT ADDRESS
$
$
$
$
$
TIME OF OFFENSE AM
PM
COLOR
AGENCY CODE OFFICER I.D. NUMBER COURT CODE OPERATOR OWNER
PASSENGER BICYCLISTR
SPEEDING ASSESSMENTS INCLUDE A $50 HEAD INJURY SURCHARGE
VIOLATOR
MV
OFFENSE
(S)
PLACARDED HAZMAT
YES NO
recyclable
1
“PR
ES
S H
AR
D - You are m
aking 5 copies.”
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 1
Sample
INSTRUCTION A (ALL CIVIL INFRACTIONS)
INSTRUCTION B (CRIMINAL APPLICATION)
If “ALL CIVIL INFRACTIONS”is checked on the front,
all the violations with w
hich you are charged are civil infractions.To avoid late fees and possible suspension/revocation of your license or registration,
you m
ust either pay this citation in full or request a court hearing WITHIN 20 DAYS of the date of offense.To
pay your citation in full,check off Box 1 (I W
ISH TO PAY THIS CITATION).To request a court hearing,
check off Box 2 (I REQUEST A COURT HEARING).Read the instructions and sign below
.If you fail to
pay this citation in full or fail to request a hearing and pay the $25 Court Filing Fee within 20 days,
you w
ill lose your right to a hearing; you will have to pay substantial late charges,
and your license/right to operate or registration w
ill be suspended/revoked.
Mail:
Make
your checkpayable
to MassDOT,
write the citation num
ber,your license num
ber and state ofissuance on the front of the check.
DO NOT MAIL CASH.
Place your payment and this citation in
the envelope provided and m
ail it to the address below.Rem
ember to check off the Paym
ent box on the Frontof the Envelope.
I WISH
TO PAYTHIS
CITATION.I am
payingthe “TOTAL DUE”
shown as a final disposition
of this citation and I am w
aivingm
y right to a civil hearingbefore a court m
agistrate.I under-
standthat such paym
entis an adm
ission of responsibility for all infractionsand any Registry
action under the law,
and may affect m
y auto insuranceprem
ium.
I also understand that such paym
ent is not an admission of guilt,
responsibility,or negligence
in any other criminal
or civil proceeding.
I REQUEST A COURT HEARING.I deny that i am
responsible for the civil infraction(s) charged on this citation,
and I request a civil hearing before a court magistrate.
I understand that I must
pay a $25 court filing fee before the court will notify m
e by mail of the date and tim
e of the hear-ing and I m
ust appear in court on the scheduled date and time.
Place your $25 court filing fee and this citation in the envelope provided and m
ail it to the address below.
Check off the hear-ing request/filing fee box on the front of the envelope.
To pay your court filing fee: Make your check payable to M
assDOT,w
rite the citation number,
your license num
ber and state of issuance on the front of the check.DO NOT M
AIL CASH.Place your $25
court filing fee and this citation in the envelope provided and mail it to the address below
.Rem
ember to
check off the Hearing Request/Filing Fee box on the front of the envelope.
Report Address Changes: All correspondence will be m
ailed to the address on file at the RMV.
It is im
portant to report address changes.I certify that I entered my correct m
ailing address on the front of the envelope and authorize the RM
V to make any necessary changes.
X
On-line at ww
w.m
ass.gov/rmv.You w
ill need your citation number,credit card or check.
You can pay your citation the following w
ays:
Phone: 617-351-4500 (from area codes 617,857,781,and 339) or 800-858-3926 from
all other MA area
codes.Monday - Friday from
9am - 5pm
.
Signature of ViolatorDate
XSIGNATURE OF VIOLATOR
DATE
XSignature of ViolatorDate
Mail Paym
ent For Citation Or Court Hearing Request And Court Filing Fee To:Citation Processing
CenterBox
55890,Boston,MA
02205-5890
If “CRIMINAL APPLICATION”
is checked you will be granted a hearing as to w
hether a criminal com
plaintshould issue againstyou
ifyou sign below and return this citationW
ITHIN 4 DAYS to the Clerk-Magistrate
of the court named on
the front of this citation.Any accompanying civil infractions w
ill be determined
during the criminal proceedings and cannot be paid in advance.
ADDRESS CHANGES MUST BE REPORTED TO
BOTHTHE
REGISTRY OFM
OTOR VEHICLES ANDTO
THE COURT.
12
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 2
Sample
COURT ADDRESS
JUDGMENT
DOCKETNUMBER
JUDGMENT DATE COMMENT
MASSACHUSETTS UNIFORM CITATION TYPE OF CITATION
MOTOR VEHICLE LICENSE NO. OF VIOLATOR STATE CLASS RACE SEX
(Initial)
STATE ZIP
NON-INVENTORY MV SEARCH
CODEYES NO
CDL LICENSE
YES NOVIOLATOR NAME (Last) (First)
ADDRESS CITY / TOWN
PLATE TYPE
LOCATION OF OFFENSE (include #, st, hwy, city or town)
A. CHAP/ SEC / SUB CRIMCIVIL
CRIMCIVIL
CRIMCIVIL
CIVILMPHINA
MPHZONE
POSTEDNOT POSTEDLIDAR
CLOCKEDRADARESTIMATED
DESCRIPTION OF OFFENSE
B.
C.
OFFICERCHECKONE ONLY
X
X
OFFICER CERTIFIES IN HAND TO VIOL.
ALL CIVIL INFRACTIONS(See instruction A on back)
CRIMINAL APPLICATION(See instruction B on back)
WARNING(No action required)
ARREST
MAILED TO VIOL. IN HAND TO VIOLATOR’S AGENT
AGENT NAME
AGENT’S LICENSE NUMBER & STATEVIOLATOR/ AGENT ACKNOWLEDGES RECEIPT OF CITATION
D. SPEEDING
90 /17 90/18
VEHICLE REGISTRATION NO. STATE YEAR CDL VEHICLE
YES NO
CRASH
YES NOASSESSMENT
TOTAL DUE
COURT ADDRESS
$
$
$
$
$
TIME OF OFFENSE AM
PM
AGENCY CODE OFFICER I.D. NUMBER COURT CODE R
SPEEDING ASSESSMENTS INCLUDE A $50 HEAD INJURY SURCHARGE
VIOLATOR
MV
OFFENSE
(S)
recyclable
1
“PR
ES
S H
AR
D - You are m
aking 5 copies.”RM
V C
OP
Y(I
F C
IVIL
) O
R C
OU
RT
CO
PY
(IF
CR
IM.)
DATE WRITTEN (MM/DD/YY)
BIRTH DATE (MM/DD/YY)
OFFENSE DATE (MM/DD/YY)
16+ PASSENGERS
YES NO
PLACARDED HAZMAT
YES NO
OPERATOR OWNER
PASSENGER BICYCLIST
MAKE AND TYPE COLOR
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 3
Sample
COURTRECORDRECORD OFCLERKHEARINGON COMPLAINTAPPLICATION
OTHERCOURTACTIONSACTION, JUDGE, ETC.
OFFENSE
DATE
DATECLERKRESULT
A.
B.
C.
D.
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 4
Sample
AG
EN
CY
CO
PY
(IF
CIV
IL)
OR
CO
UR
TC
OP
Y(I
F C
RIM
.)
COURT ADDRESS
JUDGMENT
DOCKETNUMBER
JUDGMENT DATE COMMENT
MASSACHUSETTS UNIFORM CITATION TYPE OF CITATION
MOTOR VEHICLE LICENSE NO. OF VIOLATOR STATE CLASS RACE SEX
(Initial)
STATE ZIP
NON-INVENTORY MV SEARCH
CODEYES NO
CDL LICENSE
YES NOVIOLATOR NAME (Last) (First)
ADDRESS CITY / TOWN
PLATE TYPE
LOCATION OF OFFENSE (include #, st, hwy, city or town)
A. CHAP/ SEC / SUB CRIMCIVIL
CRIMCIVIL
CRIMCIVIL
CIVILMPHINA
MPHZONE
POSTEDNOT POSTEDLIDAR
CLOCKEDRADARESTIMATED
DESCRIPTION OF OFFENSE
B.
C.
OFFICERCHECKONE ONLY
X
X
OFFICER CERTIFIES IN HAND TO VIOL.
ALL CIVIL INFRACTIONS(See instruction A on back)
CRIMINAL APPLICATION(See instruction B on back)
WARNING(No action required)
ARREST
MAILED TO VIOL. IN HAND TO VIOLATOR’S AGENT
AGENT NAME
AGENT’S LICENSE NUMBER & STATEVIOLATOR/ AGENT ACKNOWLEDGES RECEIPT OF CITATION
D. SPEEDING
90 /17 90/18
VEHICLE REGISTRATION NO. STATE YEAR CDL VEHICLE
YES NO
CRASH
YES NOASSESSMENT
TOTAL DUE
COURT ADDRESS
$
$
$
$
$
TIME OF OFFENSE AM
PM
AGENCY CODE OFFICER I.D. NUMBER COURT CODE R
SPEEDING ASSESSMENTS INCLUDE A $50 HEAD INJURY SURCHARGE
VIOLATOR
MV
OFFENSE
(S)
recyclable
1
“PR
ES
S H
AR
D - You are m
aking 5 copies.”
DATE WRITTEN (MM/DD/YY)
BIRTH DATE (MM/DD/YY)
OFFENSE DATE (MM/DD/YY)
16+ PASSENGERS
YES NO
PLACARDED HAZMAT
YES NO
OPERATOR OWNER
PASSENGER BICYCLIST
MAKE AND TYPE COLOR
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 5
Sample
IC
ER
TIFYTH
ATT
HE
INF
OR
MAT
ION
RE
LATIN
GTO
“JUD
GM
EN
T,”“JU
DG
ME
NT
DAT
E”
AN
D“C
OM
ME
NT
”,E
NT
ER
ED
ON
T
HE
R
EV
ER
SE
SID
EO
F
TH
ISC
ITATION
,ISTR
UE
AN
DC
OR
RE
CT.
AP
PR
OV
ED
CO
DE
SF
OR
US
EIN
EN
TE
RIN
GJU
DG
ME
NT
INFO
RM
ATION
ON
TH
ISA
BS
TRA
CT
CO
UR
TVA
LIDAT
ION
STA
MP
G =
G
uiltyN
G =
N
ot Guilty
R =
R
esponsibleN
R =
N
ot Responsible
DL
=
Delinquent
ND
=
Not D
elinquentF
I =
Filed
(only byjudge,w
hereallow
edby law
)
DF
=
D
efaultD
R
=
DefaultR
emoved
DI
=
Dism
issedC
W
=
Continued
WithoutF
indingN
P=
N
olleP
rosseC
D
=
Com
plaintDenied
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 6
Sample
AG
EN
CY
CO
PY
MASSACHUSETTS UNIFORM CITATION TYPE OF CITATION
MOTOR VEHICLE LICENSE NO. OF VIOLATOR STATE CLASS RACE SEX
(Initial)
STATE ZIP
NON-INVENTORY MV SEARCH
CODEYES NO
CDL LICENSE
YES NOVIOLATOR NAME (Last) (First)
ADDRESS CITY / TOWN
PLATE TYPE
LOCATION OF OFFENSE (include #, st, hwy, city or town)
A. CHAP/ SEC / SUB CRIMCIVIL
CRIMCIVIL
CRIMCIVIL
CIVILMPHINA
MPHZONE
POSTEDNOT POSTEDLIDAR
CLOCKEDRADARESTIMATED
DESCRIPTION OF OFFENSE
B.
C.
OFFICERCHECKONE ONLY
X
X
OFFICER CERTIFIES IN HAND TO VIOL.
ALL CIVIL INFRACTIONS(See instruction A on back)
CRIMINAL APPLICATION(See instruction B on back)
WARNING(No action required)
ARREST
MAILED TO VIOL. IN HAND TO VIOLATOR’S AGENT
AGENT NAME
AGENT’S LICENSE NUMBER & STATEVIOLATOR/ AGENT ACKNOWLEDGES RECEIPT OF CITATION
D. SPEEDING
90 /17 90/18
VEHICLE REGISTRATION NO. STATE YEAR CDL VEHICLE
YES NO
CRASH
YES NOASSESSMENT
TOTAL DUE
COURT ADDRESS
$
$
$
$
$
TIME OF OFFENSE AM
PM
AGENCY CODE OFFICER I.D. NUMBER COURT CODE R
SPEEDING ASSESSMENTS INCLUDE A $50 HEAD INJURY SURCHARGE
VIOLATOR
MV
OFFENSE
(S)
recyclable
1
“PR
ES
S H
AR
D - You are m
aking 5 copies.”
DATE WRITTEN (MM/DD/YY)
BIRTH DATE (MM/DD/YY)
OFFENSE DATE (MM/DD/YY)
16+ PASSENGERS
YES NO
PLACARDED HAZMAT
YES NO
OPERATOR OWNER
PASSENGER BICYCLIST
MAKE AND TYPE COLOR
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 7
Sample
OFFIC
ER
’S N
OT
ES
FOR
TE
ST
IFYIN
GIN
CO
UR
T
Please note
factsand
circumstances
in additionto
tho
sech
ecke
do
nthe face
of the citation, that is:
(1) any specificaction of
violator w
hich
increased the hazard of the violation;(2)
where
violation observedand w
here contactm
ade;(3)
totaldistance
traveled during pursuit;
(4) statem
ents by violator and general
attitu
de
.
WE
AT
HE
R
NO
.LAN
ES
:
CLE
AR
CLO
UD
Y
RA
IN
SN
OW
FO
G
SLE
ET
HIG
HW
AY
DR
Y
WE
T
MU
DD
Y
SN
OW
Y
ICY
DIV
IDE
D
TR
AF
FIC
LIGH
T
ME
DIU
M
HE
AV
Y
LIGH
T
DA
YLIG
HT
DA
RK
NE
SS
DA
WN
DU
SK
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 8
Sample
OF
FIC
ER
C
OP
Y
MASSACHUSETTS UNIFORM CITATION TYPE OF CITATION
MOTOR VEHICLE LICENSE NO. OF VIOLATOR STATE CLASS RACE SEX
(Initial)
STATE ZIP
NON-INVENTORY MV SEARCH
CODEYES NO
CDL LICENSE
YES NOVIOLATOR NAME (Last) (First)
ADDRESS CITY / TOWN
PLATE TYPE
LOCATION OF OFFENSE (include #, st, hwy, city or town)
A. CHAP/ SEC / SUB CRIMCIVIL
CRIMCIVIL
CRIMCIVIL
CIVILMPHINA
MPHZONE
POSTEDNOT POSTEDLIDAR
CLOCKEDRADARESTIMATED
DESCRIPTION OF OFFENSE
B.
C.
OFFICERCHECKONE ONLY
X
X
OFFICER CERTIFIES IN HAND TO VIOL.
ALL CIVIL INFRACTIONS(See instruction A on back)
CRIMINAL APPLICATION(See instruction B on back)
WARNING(No action required)
ARREST
MAILED TO VIOL. IN HAND TO VIOLATOR’S AGENT
AGENT NAME
AGENT’S LICENSE NUMBER & STATEVIOLATOR/ AGENT ACKNOWLEDGES RECEIPT OF CITATION
D. SPEEDING
90 /17 90/18
VEHICLE REGISTRATION NO. STATE YEAR CDL VEHICLE
YES NO
CRASH
YES NOASSESSMENT
TOTAL DUE
COURT ADDRESS
$
$
$
$
$
TIME OF OFFENSE AM
PM
AGENCY CODE OFFICER I.D. NUMBER COURT CODE R
SPEEDING ASSESSMENTS INCLUDE A $50 HEAD INJURY SURCHARGE
VIOLATOR
MV
OFFENSE
(S)
recyclable
1
DATE WRITTEN (MM/DD/YY)
BIRTH DATE (MM/DD/YY)
OFFENSE DATE (MM/DD/YY)
16+ PASSENGERS
YES NO
PLACARDED HAZMAT
YES NO
OPERATOR OWNER
PASSENGER BICYCLIST
MAKE AND TYPE COLOR
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 9
Sample
OFFIC
ER
’S N
OT
ES
FOR
TE
ST
IFYIN
GIN
CO
UR
T
Please note
factsand
circumstances
in additionto
tho
sech
ecke
do
nthe face
of the citation, that is:
(1) any specificaction of
violator w
hich
increased the hazard of the violation;(2)
where
violation observedand w
here contactm
ade;(3)
totaldistance
traveled during pursuit;
(4) statem
ents by violator and general
attitu
de
.
WE
AT
HE
R
NO
.LAN
ES
:
CLE
AR
CLO
UD
Y
RA
IN
SN
OW
FO
G
SLE
ET
HIG
HW
AY
DR
Y
WE
T
MU
DD
Y
SN
OW
Y
ICY
DIV
IDE
D
TR
AF
FIC
LIGH
T
ME
DIU
M
HE
AV
Y
LIGH
T
DA
YLIG
HT
DA
RK
NE
SS
DA
WN
DU
SK
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 10
Sample
REMOVE THIS EDGE BEFORE MAILING
REMEMBER:
R
Check off either the "Payment" or "Hearing Request/Filing Fee" box on the front of this envelope.When paying the citation or requesting a hearing and paying the court filing fee, write the citation number, your license number and state of issue on your check or money order.DO NOT SEND CASH.Enclose the original citation. Make a copy of the citation for your own records.Do not include letters or other information you want a court magistrate to consider; instead, bring this information to your hearing.Report address changes on the front of this envelope.
••
••
•
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 11
Sample
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 12
Sample
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 13
Sample
PLACE STAMPHERE
The Post Officewill not delivermail without
postage
TO SEAL REMOVE BACK FLAP ONLY, MOISTEN OTHER SIDE OF THIS FLAP, AND FOLD OVER.
CHECK HERE IF NEW ADDRESS
PAYMENT
HEARING REQUEST/FILING FEE
CITATION PROCESSING CENTER
PO BOX 55890BOSTON, MA 02205-5890
Mass Uniform Citation 2012 1/10/12 1:53 PM Page 14
Sample