Solano — Declaration / Ability to Pay or to Dismiss Civil Assessment (Current Case or After Failure to Appear)

Source: https://solano.courts.ca.gov/system/files/form-4889-tr-declaration-ability-pay-or-dismiss-civil-assessment-website.pdf

4889A-TR SUPERIOR COURT OF CALIFORNIA COUNTY OF SOLANO CRIMINAL/TRAFFIC DIVISION

Criminal and Traffic Fairfield Branch Criminal and Traffic Vallejo Branch 1st floor, Hall of Justice 1 st floor, Solano Justice Center 600 Union Avenue 321 Tuolumne Street Fairfield, CA 94533 Vallejo, CA 94590

INSTRUCTIONS - DECLARATION / ABILITY TO PAY OR TO DISMISS CIVIL ASSESSMENT (CURRENT CASE OR AFTER FAILURE TO APPEAR) FORM (4889-TR)

GENERAL INSTRUCTION: A separate declaration must be completed for each case. Submit the signed and completed form, along with the supporting documentation, by mail or in-person to either location listed above, or mail to the office of the Private Collection Agency which referred you to complete this form. INSTRUCTIONS FOR COMPLETING THE FORM

Section ITEM INSTRUCTION Number 1 Your Information Current address and telephone number are required. This information will be used to notify you of the Judge’s decision concerning your case. 2 What Kind of Help do You Check all that apply. Want from the Court 2.1 Lower the Fine – Check this box if you are requesting to lower your fine. 2.2 Credit for Time Served - Check this box if you are requesting to apply credit for time served in jail or residential treatment in lieu of paying a portion or the full amount of your fine. Submit a booking summary or court order that outlines the location and amount of time served. 2.3 Community Service - Check this box if you are requesting to provide community service in lieu of paying a portion or the full amount of your fine. 2.4 Accept Proof of Correction – Check this box if you are requesting the Court accept proof for a correctable violation. Attach a copy of the document that verifies the correction was completed. 2.5 Release DMV License Hold (Abstract) – Check this box if you are requesting the Court lift a DMV hold on your driver’s license. 2.6 Traffic School – Check this box only if are eligible to attend traffic school as indicated on your Courtesy Notice and your due date has not yet passed. If you failed to appear or take action by your due date or extended due date, you are no longer eligible for Traffic School. 2.7 Other Relief – Check this box if you are requesting other relief and specify the type of relief you are seeking. 3 Request to Dismiss Civil If you are asking the Court to dismiss late fees for Failure to Appear, Failure to Pay, or Assessment the Civil Assessment, check box for section 3.1 and be sure to give the reason(s) for your failure to appear or pay. Please note that applicable proof must be attached and coincide with the time period in question. If you select any box in section 3, provide the reasons for the failure to appear or pay in the space provided in section 8. 4 Can you afford to pay? Yes - Check this box if you can afford to pay. Skip sections 5 and 6. Complete sections 7, 8 and 9 No – Check this box if you cannot afford to pay. If you check this box you must also complete sections 5, 6, 7, 8 and 9.

1

4889A-TR

5 Are you now Receiving If you are now receiving any public benefits, select all public benefit types that apply to Public Benefits? you. If you select any box in section 5, provide supporting documentation that proves you are getting benefits. Examples of supporting documentation may include, but is not limited to, evidence of public benefits or government assistance, evidence of monthly income, and/or evidence of disability. 6 Are you homeless or living Homeless - Check this box if you are currently homeless. Indicate where you usually in a shelter or transitional sleep. living facility? Shelter or Transitional Living Facility – Check this box if you currently live in a shelter or transitional living facility. Indicate the name of the shelter or transitional living facility. 7 Household Income Skip this section if you completed sections 5 and 6. Monthly income should include your monthly salary, your spouse or domestic partner’s monthly salary, any self-employed monthly income, and child support and alimony that you are receiving on a monthly basis. The number of people in household includes yourself, your spouse or domestic partner, your children and other dependents who are living with you for more than 6 months in a year. Attach a copy of any document(s) that proves the amount of gross- monthly income (before tax) for your entire household. 8 Additional Information Provide in detail the reason why you previously failed to appear or pay. You may also provide any details or special circumstances you want the Court to consider in this section. Attach a separate sheet if you need more space. 9 Applicant's Signature Sign and date your declaration. 10 Plea Form In order for the Court to consider your declaration, a plea of guilty/not guilty must be entered for all charges. If it is your intent to plead guilty or no contest, complete the attached Plea Form and date and sign the bottom of the form.

2

SUPERIOR COURT OF CALIFORNIA 4889-TR COUNTY OF SOLANO CRIMINAL/TRAFFIC DIVISION

Hall of Justice Solano Justice Center
600 Union Avenue 321 Tuolumne Street
P.O. Box 2463 Vallejo, CA 94590
Fairfield, CA 94533

DECLARATION / ABILITY TO PAY OR TO DISMISS CIVIL ASSESSMENT Case Number: (CURRENT CASE OR AFTER FAILURE TO APPEAR) Clerk fills out this box If you have more than one case, use one form for each case. No FTA – No CIVA (Current Case)

1. Your Information FTA CIVA $ ___________ Name: FTA (Court Collections)

   FTA (Collection Agency)

   Mailing Address:

   $

   City: State: Zip: Amount ordered Due date

   Tel.: Date of Birth: $ Amount paid Date paid

   E-mail (optional): Balance due: $

2. What kind of help do you want from the court? (Check all that apply to your request.) 2.1 Lower the fine 2.3 Community Service 2.6 Traffic School (Current Cases only - 2.2 Credit for time served 2.4 Accept Proof of Correction Failure to Appear cases not eligible) in jail or residential 2.5 Release DMV License Hold 2.7 Other Relief: ____________________ treatment program (Abstract)

3. Request to Dismiss Civil Assessment (Complete this section in its entirety, if applicable) 3.1 Dismiss Civil Assessment

   I failed to appear or pay because one or more of the following reasons existed at the time I was scheduled

   to appear or pay. (Check all that apply.) Hospitalization Death of Immediate Family Member Physically Incapacitated In Jail or Residential Treatment Program Military Absence Other (specify): Important! Attach a copy of any document that proves you were unable to appear or pay when scheduled to do so. Use the space in Item 8 to explain the reasons you checked for your failure to appear or pay.

4. Can you afford to pay? Yes (Skip Sections 5 and 6; Complete Sections 7, 8 and 9)

   No (If you check this box, you must also fill out Sections 5, 6, 7*, 8 and 9.)

5. Public Benefits – Check any benefits listed below that you are receiving now. If you do not receive benefits, go to the next question. Medi-Cal CalFresh/WIC CalWorks CAPI SSI/SSP Low-Income Veterans Pension Tribal TANF Refugee Cash Assistance General Assistance Extended Foster Care IHSS Other need-based help (specify): Important! Attach a copy of any document that proves you are getting the benefits you checked.

6. Homeless or Temporary Housing If you are homeless, live in a shelter, or in a transitional living facility, check below. Homeless (Where do you usually sleep?): Shelter or Transitional living facility (Which one?):

Mandatory Form DECLARATION / ABILITY TO PAY OR TO DISMISS CIVIL ASSESSMENT Page 1 of 2

Form # 4889-TR EFF. 9-12-2022 (CURRENT CASE OR AFTER FAILURE TO APPEAR)

Case Number: Applicant’s Name:

7. Household Income *(skip this section if you checked any public benefits in Item 5 or any box in Item 6)

   Monthly income $______________________

   Number of people in household: __________

   Important! Attach a copy of any document(s) that proves the amount of gross-monthly income (before tax deductions) for your household. In Item 8, provide any details or special circumstances you want the court to consider.

8. Additional Information Please explain the reason for your request and why you previously failed to appear or pay. Include any details or special circumstances you want the court to consider. (Attach more pages if you need more space.)

9. Read and sign below. I declare under penalty of perjury under the laws of the State of the California that the information I have provided on this form is true and correct.

   Date: Applicant signs here

10. Complete the attached Plea Form (Required for the Court to consider your declaration.) For Court Use Only

Court’s Decision Granted No(s): _____ 2.1 _____ 2.2 _____ 2.3 _____ 2.4 _____ 2.5 _____ 2.6 _____ 2.7 _____ 3.1 Denied No(s): _____ 2.1 _____ 2.2 _____ 2.3 _____ 2.4 _____ 2.5 _____ 2.6 _____ 2.7 _____ 3.1

Fine reduced to $ _______________________________________________________________________________

Other Orders___________________________________________________________________________________

---

---

---

Date: ______________________ _______________________________________________ JUDICIAL OFFICER

Submitted by: ___________________________________ Clerk Name

Mandatory Form DECLARATION / ABILITY TO PAY OR TO DISMISS CIVIL ASSESSMENT Page 2 of 2 Form # 4889-TR EFF. 9-12-2022 (CURRENT CASE OR AFTER FAILURE TO APPEAR)

Superior Court of California Criminal/Traffic Division Solano County Case No. Plea Form (Infractions)

Fill out this form if: You accept the charges on your infraction ticket, You want to plead guilty or no contest in this case, and You want to plead using this form instead of going to court.

1 Your Information Name: Case Number: Street or Mailing Address: Tel.: Email (optional): Date of Birth:

2 Charges I am pleading guilty or no contest to the following traffic infraction(s): Section and Code:

3 You have the following rights: To have a lawyer represent you (at your expense). To an interpreter if you do not speak English well. To a speedy court trial within 45 days of your first court date. At that trial, you have the right to not testify against yourself, to subpoena witnesses to testify for your case, and to see and question witnesses. To appeal the court’s decision.

4 If you check Guilty or No contest below, that means: You accept the charge(s) on the ticket. There will not be a trial or witnesses. You give up the rights explained on this form. A “no contest” plea is basically the same as a “guilty” plea. It is a way of saying, “I don’t believe I did all that the officer charges, but I admit violating the law.” This plea is traditionally used if there was an accident or other reason you don’t want the plea to be used as an admission of liability in a civil case related to the incident.

5 Your Plea Check one: Guilty No Contest

I declare under penalty of perjury under the laws of the State of the California that there are facts to support my plea, and that the information I have provided on this form is true and correct.

Date: Sign here

FORM 4874-TR PLEA FORM Page 1 of 1 MANDATORY