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You have failed to pay your fine. This Court will order you to pay a civil assessment of $300.00

SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL FOR COURT USE ONLY 939 W. Main Street El Centro, CA 92243

DEFENDANT:

REQUEST TO VACATE CIVIL ASSESSMENT CASE NUMBER:
(PC1214.1(b))

in addition to your original fine unless good cause is shown for your failure to pay. If you have good cause to excuse your failure to pay, complete the information below. Written proof of any of the following must be attached and cover the time period in question. [ ] Hospitalization [ ] Incarceration [ ] Overseas Military Duty [ ] Extenuating Circumstance The following is an explanation for my failure to pay or appear:

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I declare under penalty of perjury that the above is true and correct to the best of my knowledge.

Executed at ________________________________, on __________________________(date) (city, state)

Name (print) Area Code/Telephone #_

Address, City, State, Zip ________________________________________________________

Signature of Defendant: _____________________________________

Staff review: ___________________________________ Date: ______________________ Documents Support Request Documents do not Support Request ORDER RE: VACATING CIVIL ASSESSMENT (COURT USE ONLY) FOR COURT USE ONLY The Court having read and considered the Petition and evidence regarding vacating the Civil Assessment pursuant to PC 1214.1(b), hereby makes the following order. Judgment on the charge(s) will not be set aside. Request to vacate is: [ ] Granted [ ] Denied

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Date Judicial Officer

Form Approved for Mandatory Use REQUEST TO VACATE CIVIL www.imperial.courts.ca.gov CL-01 (Adopted 01/01/10, Revised 01/01/12, ASSESSMENT (PC1214.1(b)) 01/01/13, 01/01/16)