2. Make sure you have reviewed the eligibility details before submitting this form.
4. First Name*
5. Last Name*
7. Phone Number*
8. Email Address*
10. Citation Number*
11. Vehicle License Plate*
13. Demographic Information*

    We collect this information as part of our commitment to ensure we are creating programs that serve our diverse community. This information is optional. Please Check One:

    1. Black/African-American
    2. White/Caucasian
    3. Hispanic/Latino
    4. Other

    1. Native American
    2. Asian/Pacific Islander
    3. Asian Indian
    4. Prefer Not to Respond
14. Gender

    Please Check One:

    1. Male
    2. Female
    3. Non-binary
    4. Other
    5. Prefer not to Respond

16. Participation in the Citation Payment Plan will be based on 200% of federal poverty levels 

    Once this form is submitted, a member of our staff will contact you to certify proof of eligibility (e.g., driver’s license, proof of income, proof of receipt of public assistance benefits). Documents will not be copied, scanned, or kept. The documents will merely be reviewed in person.

    Once approved, you will be required to create an account in AIMS, our customer portal, and will receive a monthly statement via email with payment due by the 15th.  

    Applications are also available in our Park Durham Customer Service Center, located at 105 W. Morgan St., Suite 104. Our staff will be happy to assist you Monday through Thursday from 8 a.m. to 5 p.m., and on Friday from 10 a.m. to 5 p.m.  

Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field