San Bernardino — SB-16351

Source: https://sanbernardino.courts.ca.gov/system/files/sb-16351.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO CONFIDENTIAL

STREET ADDRESS: FOR COURT USE ONLY CITY AND ZIP CODE: DISTRICT NAME:

PLAINTIFF: People of the State of California vs.

REQUEST FOR CONSIDERATION OF ABILITY TO PAY

Fill out this form to request a lower fine, a payment plan, more time to Citation or Case No.: pay, and/or community service. This form is used for infractions only, and cannot be used for misdemeanors, parking tickets, or felonies.

Charges: 1.§ 2.§ 3.§ 4.§ 5.§

WHAT IS THE STATUS OF THIS CASE? Please check only one. ☐ OPTION 1: I have NOT been to Court or signed an agreement to pay fines/fees on this citation, OR ☐ OPTION 2: I HAVE been to Court on this ticket, but no pleas were entered and no fines/fees were set, OR ☐ OPTION 3: The case has been heard by the Court and fines/fees imposed. I am requesting a modification to the current order.

IF YOU CHOOSE OPTION 1 OR 2, YOU MUST READ AND INITIAL THE FOLLOWING: I want to plead guilty to all charges and have the court rule on my fines/fees. I have read the Advisal of Rights on the reverse of this form, and I understand my initials and signature on this form are an admission of GUILT and my Driver’s License may be affected. _______ (initial here)

REQUEST WHAT ARE YOU ASKING THE COURT TO DO? Check all that you are willing and able to do: (I understand that, by law, some fines/fees cannot be lowered.) Lower the amount I owe on the fine. Give me more time to pay the fine or allow me to make monthly payments. Lower my current monthly payments to $_________________ per month. Allow me to serve community service instead of paying a fine. Check this box if this is not your first request to lower your fine or serve community service for this case.* * If you check this box, you must attach a statement telling the Court what has changed since your last request.

PERSONAL INFORMATION: Your Name: Mailing Address:

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Date of Birth: City, State, Zip Code:

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Driver’s License Number: Telephone Number:

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Local Court Form (Rev. 07/01/2018) REQUEST FOR CONSIDERATION OF ABILITY TO PAY Page 1 of 2 SB-16351 (Optional Use) CONFIDENTIAL

Case Name: Citation or Case Number:

INCOME INFORMATION:

Your Monthly Income: $ Source (Job, TANF, SSI, Disability, etc.) Other Household Income: $ Source (Job, TANF, SSI, Disability, etc.) Number of Children in Household: Total number in Household: I currently receive the following (check all that apply): ☐ AFDC/TANF ☐CalFresh ☐CalWorks or Tribal TANF ☐CAPI ☐County Relief/General Assistance Your Monthly Expenses (list amounts for all that apply): Car/Gas: Childcare: Child Support: Food: Health Insurance: Rent/Mortgage: Student Utilities

Please provide any additional information or documentation:

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ADVISEMENT OF RIGHTS

By choosing to pay and forfeit bail and not go into court, you will be giving up these rights: To appear in court without deposit of bail for formal arraignment, plea, and sentencing; To request and have a court trial without deposit of bail, unless the court orders bail, and challenge the charges; To have a speedy court trial and have the charges dismissed if a speedy trial is requested but not provided; To be represented by an attorney at your expense; To subpoena or present witnesses and physical evidence using the power of the court at no cost to you and to testify on your own behalf; To confront and cross-examine all witnesses under oath testifying against you and To remain silent and not testify.

I declare under penalty of perjury, under the laws of the State of California, that all information on this form, including any attachments, is true and correct.

Signature Date

Print your name here

Local Court Form (Rev. 07/01/2018) ORDER ON REQUEST FOR CONSIDERATION OF ABILITY TO PAY Page 2 of 2 SB-16351 (Optional Use) CONFIDENTIAL