Superior Court of California, County of Contra Costa P.O. Box 5128 Walnut Creek, CA 94596-5128 CIVIL ASSESSMENT PETITION AND ORDER DEFENDANT’S REQUEST AND DECLARATION TO VACATE CIVIL ASSESSMENT Defendant’s Name __________________________________________ Case Number _______________ IMPORTANT: Written proof of any of the following that shows you were unable to appear or contact the court must be attached. HOSPITALIZED RESIDENTIAL TREATMENT NOT PERSON CITED INCARCERATED DEATH CERTIFICATE CLERICAL ERROR MILITARY DUTY The following is an explanation of my failure(s) to appear and/or pay: (Please print and include attachments) I declare under penalty of perjury that the foregoing statement is true and correct to the best of my knowledge and that written proof is attached to this form. Executed at ________________________________________ on _____________________ City and State Date Address ________________________________________________ ________________________________________________ Telephone # __________________________________ Signature _________________________________ ORDER re. CIVIL ASSESSMENT (COURT USE ONLY) The Court having read and considered the Petition regarding vacating the Civil Assessment pursuant to PC 1214.1(B), hereby makes the following order: Defendant’s Petition to Vacate is: DENIED GRANTED Signature _______________________________ Commissioner Date _______________ For questions on your fine amount, please contact the appropriate court location below. Walnut Creek Court 640 Ygnacio Valley Rd. Walnut Creek, CA 94596 925-646-6572 Local Court Form – Mandatory TR-121 Rev 5/12/11 Concord Court 2970 Willow Pass Rd. Concord, CA 94519 925-646-5404 Pittsburg Court 1000 Center Drive Pittsburg, CA 94565 925-427-8170 Richmond Court th 100 37 Street Richmond, CA 94805 510-374-3171 American LegalNet, Inc. www.FormsWorkFlow.com