Fresno — TR-105RC Petition for Consideration re Ability to Pay

Source: https://www.fresno.courts.ca.gov/system/files/ptr-105rc-petition-consideration-re-ability-pay.pdf

Petition For Consideration re CONFIDENTIALTR-105RC Ability to Pay Clerk stamps date here when form is filed. Note: You MUST complete pages 1 and 2 of this form

You may file this request if you have a financial hardship and can show that you are unable to pay the full amount for the offense(s) on your case, you may request the Court to consider your ability to pay in setting the fine amount. Also, if you are ordered to pay a fine you may ask the Court for an installment payment plan that is based on your ability to pay, or ask the Court to approve community service or Fill in court name and street address: alternative to paying the fine due to financial hardship. However, you must appear before the Court to do so. This form should be completed when you appear in court. Superior Court of California, County of FresnoYou may be asked to provide financial documentation in support of your request. Traffic Department 2317 Tuolumne Street Fresno, California 93721 1 Your Information: Name: Fill in case number and name: Case Number: Street or mailing address: City: State: ZIP: Case Name: Phone number:

2 Your Job, if you have one (job title): Employer's address: Name of employer:

3 Your Lawyer, if you have one (name, firm or affiliation, address, phone number, and State Bar number):

a. The lawyer has agreed to represent you without charging fees or costs (check one): Yes No
b. (If yes, your lawyer must sign here): Lawyer's signature:
If no, and your lawyer is not providing legal-aid type services based on your low income, please
explain below and on page 2.

4 I am requesting consideration of the Court on this case based on my "ability to pay determination".

a. I receive (check all that apply): Medi-Cal Food Stamps SSI SSP County Relief/ General Assistance IHSS (In-Home Supportive Services) CalWORKS or Tribal TANF (Tribal Temporary Assistance for Needy Families) CAPI (Cash Assistance Program for Aged, Blind and Disabled) b. My gross monthly household income (before deductions for taxes) is less than the amount listed below. Family Size Family Income Family Size Family Income Family Size Family Income If more than 6 people 1 $1,264.59 3 $2,164.59 5 $3,064.59 at home, add $450.00 for each extra person. 2 $1,714.59 4 $2,614.59 6 $3,514.59

c. I do not have enough income or available credit to pay for my household's basic needs. (Explain):

PTR-105RC R03-18 Petition For Consideration re Ability to Pay Page 1 of 3 MANDATORY

Case Number: Your name:

You must fill out this entire page.

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

Date: /S/ Print your name here Sign here

5 Check here if your income changes a lot from month to month. 8 Your Money, Assets, and Property Fill out below based on your average income for the past 12 a. Cash $ months. b. All financial and credit accounts (List bank and available balance): 6 Your Monthly Income (1) $ a. Gross monthly income (before deductions): $ (2) $ List each payroll deduction and amount below: (3) $ (1) $ (4) $ (2) $ (3) $ c. Cars, boats, and other vehicles (4) $ Fair Market How Much You Make / Year Value Still Owe b. Total deductions (add 8a (1)-(4) above): $ (1) $ $ c. Total monthly take-home pay (8a minus 8b): $ (2) $ $ d. List the source and amount of any other income you get each (3) $ $ month, including: spousal/child support, retirement, social security, disability, unemployment, military basic allowance for d. Real estate Fair Market How Much You quarters (BAQ), veterans payments, dividends, interest, trust Address Value Still Owe income, annuities, net business or rental income, (1) $ $ reimbursement for job-related expenses, gambling or lottery winnings, etc. (2) $ $ (1) $ (3) $ $ (2) $ e. Other personal property (stocks, bonds, jewelry, furniture, (3) $ collectables, antiques, art, etc.): Fair Market How Much You (4) $ Describe Value Still Owe (1) $ $ e. Your total monthly income is (8c plus 8d): $ (2) $ $ (3) $ $ 7 Household Income a. List all other persons living in your home and their income; 9 Your Monthly Expenses include only your spouse and all individuals who depend in (Do not include payroll deductions you already listed in 8b.) whole or in part on you for support, or on whom you depend in a. Rent or house payment & maintenance $ whole or in part for support. b. Food and household supplies $ Gross Monthly Name Age Relationship Income c. Utilities and telephone $ (1) $ d. Clothing $ (2) $ e. Laundry and cleaning $ (3) $ f. Medical and dental expenses $ (4) $ g. Insurance (life, health, accident, etc.) $ h. School, child care $ i. Child, spousal support (another marriage) $ b. Total monthly income of persons above: $ j. Transportation, gas, auto repair and insurance $

ld care $ i. Child, spousal support (another marriage) $ b. Total monthly income of persons above: $ j. Transportation, gas, auto repair and insurance $ k. Installment payments (list each below): Total monthly income and Paid to: How Much? household income (8e plus 9b): $ (1) $ (2) $ (3) $ l. Wages/earnings withheld by court order $

PTR-105RC R03-18 Petition For Consideration re Ability to Pay Page 2 of 3 MANDATORY

Case Number: Your name:

9 Your Monthly Expenses (cont.) To list any other facts you want the Court to know, such as unusual medical expenses, family emergencies, etc., m. Any other monthly expenses (list each below). $ attach form MC-025. Or attach a sheet of paper, and Paid to: How Much? write Financial Information and your name and case (1) $ number at the top. Check here if you attach another (2) $ page. (3) $ Total monthly expenses (add 11a –11m above): $

/S/
Signature

For Judicial Use

Granted Denied

Balance of Fine and or Fees Suspended Driver license hold remains based on the ability to pay
determination
Community Service hours to be complete through
by The Court orders:

Installment payments of $ per month
beginning with additional $35.00 installment
plan fee

Fine modified to / by $ due forthwith.

Fine modified to / by and payable in full by
with additional $30.00 time to pay fee

Fine modified to / by and payable in full by
with additional $30.00 time to pay fee

Fine modified to / by , payable in
installments of per month beginning
with additional $30.00 time to pay fee

Case recalled from GC/MSB Collection Agency

Driver license hold lifted

Court orders:

SIGN

Date:
Judge's Signature

PTR-105RC R03-18 Petition For Consideration re Ability to Pay Page 3 of 3 MANDATORY