Solano — Declaration to Dismiss Civil Assessment - Ability to Pay (After Failure to Pay or Trial in Absentia)

Source: https://solano.courts.ca.gov/system/files/form-4890-tr-declaration-dismiss-civil-assessment-ability-pay-website.pdf

4890A-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 TO DISMISS CIVIL ASSESSMENT / ABILITY TO PAY (AFTER FAILURE TO PAY OR TRIAL IN ABSENTIA) FORM (4890-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 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 2.1 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 2, provide the reasons for the failure to appear or pay in the space provided in section 4. 3 Ability to Pay Check all requests and information that apply to you. 3.1 Lower the fine Check this box if you are requesting to lower your fine. 3.2 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. 3.3 Other relief Check this box if you are requesting other relief and specify the type of relief you are seeking. 3.4 Credit for time served in jail Check this box if you are requesting to apply credit for time served in jail or residential or residential treatment 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. 3.5 I am now receiving one or Check this box if applicable and select all public benefit types that apply to you. If you more of the following select any box in section 3.5, provide supporting documentation that proves you are Public Benefits 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. 3.6 I am either homeless of Check this box if applicable, select which kind is applicable to you, and indicate the place living in a Shelter where you usually sleep, or the name of the shelter or transitional living facility. 3.7 Household Income Skip this section if you completed section 3.5 and 3.6. 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. 4 Additional Information Provide in detail the reason why you previously failed to appear or pay. You may also provide any details or circumstances you want the Court to consider in this section. Attach a separate sheet if you need more space. 5 Applicant's Signature Sign and date your declaration.

SUPERIOR COURT OF CALIFORNIA 4890-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 TO DISMISS CIVIL ASSESSMENT / ABILITY TO PAY Case Number: (AFTER FAILURE TO PAY OR TRIAL IN ABSENTIA) Clerk fills out this box If you have more than one case, use one form for each case. FTP - No CIVA (Not in Collections)

1. Your Information FTP (In Collections) CIVA $_______ TIA (Not In Collections) Name: TIA (In Collections)

   Mailing Address: $ Amount ordered Due date City: State: Zip: $ Amount paid Date paid Tel.: Date of Birth: Balance due: $

   E-mail (optional):

2. Request to Dismiss Civil Assessment (Complete this section in its entirety, if applicable) 2.1. 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 and explain in details the reason why you previously failed to appear or pay in the space provided in section 4): Hospitalization Death of Immediate Family Member Physically Incapacitated In Jail In Residential Treatment Program Military Absence Other: _______________________________ (Attach any document that proves you were unable to appear or pay when scheduled to do so)

3. Ability to Pay (Check all that apply to your request) 3.1. Lower the fine 3.2. Community Service 3.3. Other Relief:_______________________________ 3.4. Credit for time served in jail or residential treatment program 3.5. I am now receiving one or more of the following Public Benefits (Check all that apply to you): 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):_____________________________________________ (Attach a copy of any document that proves you are getting the benefits you checked above) 3.6. I am either homeless or living in a Shelter/Transitional Living Facility (Check one below): Homeless (Where do you usually sleep?): ________________________________________ Shelter or Transitional living facility (Which one?): _________________________________

Mandatory Form DECLARATION TO DISMISS CIVIL ASSESSMENT/ABILITY TO PAY Page 1 of 2 Form # 4890-TR EFF. 9-12-2022 (AFTER FAILURE TO PAY OR TRIAL IN ABSENTIA)

Case Number: Applicant’s Name:

3.7. My household income is as follows: (Skip this section if you completed section 3.4 and 3.5 above; attach a copy of any document(s) that proves the amount of gross-monthly income (before tax deductions) for your household) Monthly income $______________________ Number of people in household: __________

4. Additional Information (Provide in the space below the reason why you previously failed to appear or pay, and any details or circumstances you want the court to consider. Attach a separate sheet if you need more space.)

5. Applicant’s Signature (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 For Court Use Only

Court’s Decision Granted No(s): _____ 2.1 _____ 3.1 _____3.2 _____ 3.3 _____ 3.4 Denied No(s): _____ 2.1 _____ 3.1 _____3.2 _____ 3.3 _____ 3.4

Fine reduced to $ ______________________________________________________________________________

Other Orders__________________________________________________________________________________

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Date: ______________________ ______________________________________________ JUDICIAL OFFICER

Submitted by: __________________________________ Clerk Name

Mandatory Form DECLARATION TO DISMISS CIVIL ASSESSMENT/ABILITY TO PAY Page 2 of 2 Form # 4890-TR EFF. 9-12-2022 (AFTER FAILURE TO PAY OR TRIAL IN ABSENTIA)