N.Y. Comp. Codes R. & Regs. tit. 15 § 92.1
Except as provided in section 92.2 of this Part, the following form is to be used in disposing of certain traffic infractions pursuant to the provisions of section 1805 of the Vehicle and Traffic Law.
PLEA OF GUILTY
Instructions to Motorists: Submit this form to the Court by Registered or Certified mail, Return Receipt Requested. This form may not be used for misdemeanors or for a third or subsequent speeding violation in an 18-month period. If the court denies this application, the applicant will be notified to appear.
To:
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[] City
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[] Town
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[] Village COURT,
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[] City
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[] Town
[] Village OF __
I, __ residing at __ have been charged with __ committed on __at __ I acknowledge receipt of the following warning:
"A PLEA OF GUILTY TO THIS CHARGE IS EQUIVALENT TO A CONVICTION AFTER TRIAL. IF YOU ARE CONVICTED, NOT ONLY WILL YOU BE LIABLE TO A PENALTY, BUT IN ADDITION YOUR LICENSE TO DRIVE A MOTOR VEHICLE OR MOTORCYCLE, AND YOUR CERTIFICATE OF REGISTRATION, IF ANY, ARE SUBJECT TO SUSPENSION AND REVOCATION AS PRESCRIBED BY LAW."
I waive arraignment in open court and the aid of Counsel. I plead guilty to the offense as charged and elect and request that this charge be disposed of and fine or penalty fixed by the court. I make the following statement of explanation (optional).............................................................
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APPLICANTS UNDER 18 MUST COMPLETE THE FOLLOWING
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Name of Parent or Guardian
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Address of Parent or Guardian
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All statements are made under penalty of perjury:
Date
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Signed
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N.Y. Comp. Codes R. & Regs. Tit. 15 § 92.1