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2. In the Midlothian Municipal Court, City of Midlothian, Ellis County, Texas
4. State of Texas VS
6. First Name*
7. Last Name*
8. Date of Birth*
   Date of Birth
10. Mailing Address/ P.O. Box*
11. City*
13. State*
14. Zip Code*
15. Phone Number*
17. Citation or Cause Number*
    Typically, the Citation starts with a capital E.
19. To consider your request, the court requires the following: A plea of guilty or nolo contendere (no contest) in the cause(s) for which you are seeking jail credit and official documentation.
21. I, the above Defendant in the above referenced case, do hereby enter a plea of*
    -- Select One --Guilty, I waive my rights to a trial by jury.No Contest, I waive my rights to a trial by jury
23. Specific name of the facility and location where you were or are currently incarcerated.*
24. The date when you began your incarceration period*
    The date when you began your incarceration period
26. The date you were released on or if presently in custody, the expected date of release*
    The date you were released on or if presently in custody, the expected date of release
27. Submit Incarcerated Paperwork*
29. Submit Picture of Identification Card*
    Front of ID card only
30. Email*
32. I acknowledge that all of the information entered above is true and correct. I agree that the name below will be an electronic representation of my signature for all purposes when placed on my document, including legally binding contracts - just the same as a pen and paper signature or initial.
33. Date *
    Date
Leave This Blank:


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

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field