TR-105 Petition to Waive Deposit of Bail for FTA Traffic Court Trial or Civil Assessment Application CONFIDENTIAL Clerk stamps date here when form is filed. If you are receiving public benefits, are a low-income person, or do not have enough income to pay for your household's basic needs, you may use this form to ask the Court to waive your deposit of bail. The Court may ask you to answer questions about your finances. If the Court waives the deposit of bail, you may still have to pay later if: Fill in court name and street address: 1 Your Information (person asking the court to waive deposit of bail): Name: Street or mailing address: City: State: ZIP: Phone number: Your Job, if you have one (job title): Employer's address: Name of employer: Fill in case number and name: Case Number: Case Name: 2 3 Your Lawyer, if you have one (name, firm or affiliation, address, phone number, and State Bar number): 4 5 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 why you are asking the court to waive the deposit of bail for FTA Traffic Court Trial or Civil Assessment Application. What is the bail deposit amount you are asking to be waived? $ Why are you asking the court to waive your deposit of bail for FTA Traffic Court Trial or Civil Assessment Application? 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. (If you check 5b you must fill out 7, 8 and 9 on page 2 of this form.) Family Size Family Income 1 2 $1,237.50 $1,668.75 Family Size 3 4 Family Income $2,100.00 $2,531.25 Family Size 5 6 Family Income $2,962.50 $3,393.75 If more than 6 people at home, add $433.34 for each extra person. c. I do not have enough income or available credit to pay for my household's basic needs and deposit bail. (Explain): (If you check 5c, you must fill out all of page 2 to provide additional information.) 6 Check here if you asked for a waiver of your court fees or deposit of bail for another case in the last six months. (If your previous request is reasonably available, please attach it to this form and check here: 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: Print your name here PTR-105 R08-16 MANDATORY Sign here Petition to Waive Deposit of Bail for FTA Traffic Court Trial or Civil Assessment Application Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Your name: If you checked 5a on page 1, do not fill out below. If you checked 5b, fill out questions 7, 8, and 9 only. If you checked 5c, you must fill out this entire page. If you need more space, attach form MC-025 or attach a sheet paper and write Financial Information and your name and case number at the top. 7 Check here if your income changes a lot from month to month. Fill out below based on your average income for the past 12 months. 10 8 Your Monthly Income a. Gross monthly income (before deductions): List each payroll deduction and amount below: (1) (2) (3) (4) Your Money, Assets, and Property a. Cash $ b. All financial and credit accounts (List bank and available balance): (1) $ $ $ $ $ $ $ $ $ (2) (3) (4) c. Cars, boats, and other vehicles Make / Year (1) (2) (3) $ b. Total deductions (add 8a (1)-(4) above): c. Total monthly take-home pay (8a minus 8b): $ d. List the source and amount of any other income you get each month, including: spousal/child support, retirement, social security, disability, unemployment, military basic allowance for quarters (BAQ), veterans payments, dividends, interest, trust income, annuities, net business or rental income, reimbursement for job-related expenses, gambling or lottery winnings, etc. (1) (2) (3) (4) Fair Market Value $ $ $ Fair Market Value $ $ $ $ $ $ $ $ $ How Much You Still Owe d. Real estate Address (1) (2) (3) How Much You Still Owe $ $ $ $ $ e. Other personal property (stocks, bonds, jewelry, furniture, collectables, antiques, art, etc.): Describe (1) (2) (3) Fair Market Value $ $ $ $ $ $ How Much You Still Owe e. Your total monthly income is (8c plus 8d): 9 Household Income a. List all other persons living in your home and their income; include only your spouse and all individuals who depend in whole or in part on you for support, or on whom you depend in whole or in part for support. Gross Monthly Age Relationship Income Name (1) $ (2) (3) (4) 11 Your Monthly Expenses (Do not include payroll deductions you already listed in 8b.) $ $ $ $ b. Total monthly income of persons above: Total monthly income and household income (8e plus 9b): a. b. c. d. e. f. g. h. i. j. k. $ Rent or house payment & maintenance $ Food and household supplies $ Utilities and telephone $ Clothing $ Laundry and cleaning $ Medical and dental expenses $ Insurance (life, health, accident, etc.) $ School, child care $ $ Child, spousal support (another marriage) Transportation, gas, auto repair and insurance $ Installment payments (list each below): Paid to: $ (1) (2) (3) To list any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc., attach form MC-025. Or attach a sheet of paper, and write Financial Information and your name and case number at the top. Check here if you attach another page. Important! If your financial situation improves and you are able to deposit bail, you must notify the court within five days. $ $ l. Wages/earnings withheld by court order $ m. Any other monthly expenses (list each below). $ Paid to: (1) (2) (3) How Much? $ $ $ Total monthly expenses (add 11a ­11m above): $ Granted Denied Signature PTR-105 R08-16 MANDATORY Petition to Waive Deposit of Bail for FTA Traffic Court Trial or Civil Assessment Application Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com